HX641 29500 
RC601  .P27  Psychiatry;  a  text-b 


R  C  6  0  I  P  2-7 

Columbia  Unifcerjgitp 

College  of  logicians!  anb  burgeons! 
Htbrarj* 


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PSYCHIATRY 


A  TEXT-BOOK  FOR  STUDENTS  AND  PHYSICIANS 


BY 


STEWART   PATON,  M.D. 

ASSOCIATE    IN    PSYCHIATRY,    THE   JOHNS    HOPKINS     UNIVERSITY,    EALTIMORE  ;     DIRECTOR     OF    THE 
LABORATORY,     THE    SHEPPARD    AND    ENOCH     PRATT     HOSPITAL,    TOWSON,     MARYLAND 


PHILADELPHIA   AND   LONDON 

J.    B.    LIPPINCOTT    COMPANY 

1905 


"R.C 
T^1 


Copyright,  1905 
By  J.  B.  Lippincott  Company 


Printed  by  J.  B.  Lippincott  Company,  Philadelphia,  U.  S.  A. 


La  vraie  medicine,  celle  qui  est  fondee  sur  des  principes  et  qui  consiste  bien 
moins  dans  1' administration  des  medicamens  que  dans  la  connoissance  approfondie 
des  maladies,  qui  a  ete  exercee  par  les  medecins  observateurs  de  tous  les  ages,  qui 
doit  seule  faire  la  base  de  1' instruction  publique,  est  marquee  par  d'autres  caracteres  ; 
methode  hippocratique  et  marche  rigoureuse  de  1' observation  conservees  depuis  plus 
de  vingt  siecles  dans  leur  inalterable  purete  ;  suspension  de  leurs  progres  pendant  des 
siecles  d' ignorance  et  de  barbarie,  mais  empressement  des  bons  esprits  a  les  reprendre 
ensuite  et  a  les  cultiver  comme  une  branche  de  l'histoire  naturelle  .  .  .  vues  etendues 
pour  appliquer  a  la  medicine  les  progres  faits  dans  les  autres  sciences  accessoires,  la 
chimie,  la  botanique,  la  physique,  la  philosophic  morale.    .    .    . 

Ph.  Pinel  :  Nosographie  Philosophique ,  Paris,  ijg8. 


PREFACE 


The  great  increase  of  knowledge  concerning  those  morbid 
conditions  of  the  human  body  commonly  but  erroneously  de- 
scribed as  mental  diseases,  and  the  resulting  improvements 
made  in  recent  years  in  the  methods  employed  in  the  investiga- 
tion and  treatment  of  them,  may  in  part  be  urged  as  justifying 
the  publication  of  another  book  on  Psychiatry. 

No  higher  or  more  imperative  duty  confronts  the  State 
and  institutions  of  learning  than  that  of  encouraging,  in  every 
possible  manner,  the  prosecution  of  studies  which  promise  to 
result  in  the  determination  of  the  sources  of  rational  thought 
and  action;  but  it  is  evident  that  the  main  burden  of  the  work 
must  be  borne  by  the  medical  profession,  from  whose  ranks 
must  come  the  leaders  of  any  movement  which  has  for  its 
object  the  prevention  and  cure  of  the  diseases  characterized 
by  defective  or  perverted  functioning  of  the  brain. 

In  writing  this  book  I  have  made  no  attempt  to  compose 
an  exhaustive  treatise;  my  main  object  has  been  to  call  atten- 
tion to  that  aspect  of  the  subject  which  is  in  accord  with  the 
results  of  observations  as  they  are  conducted  to-day  at  the  bed- 
side and  in  the  laboratory;  and  while  presenting  the  different 
views  of  leading  authorities  in  a  manner  readily  to  be  compre- 
hended by  students  of  this  important  branch  of  medicine,  to 
stimulate  to  greater  activity  the  interest  in  the  investigation  of 
problems  in  the  solution  of  which  will  be  found  the  means  of 
increasing  the  brain  power  of  the  nation. 

If  this  book  shall  in  any  way  serve  the  purpose  for  which  it 
has  been  written,  it  will  be  in  large  part  due  to  the  encourage- 
ment and  advice  of  many  friends,  to  whom  I  gratefully  acknowl- 
edge my  indebtedness. 

S.  P. 


CONTENTS 


CHAPTER   I 


PAGE 

The  importance,  scope,  and  methods  of  modern  psychiatry  i 

CHAPTER    II 
The  nature  of  the  disease  process  in  alienation  and  its  relation 

to  the  pathological  changes  16 

CHAPTER   III 
The  symptoms  of  alienation. 

I.  Impairment  of  the  higher   cortical   functions  as   shown  in 

defects  of  judgment  and  intellect.     Fixed  or  insane  ideas    26 
II.  Anomalies    in    the   intensity    and    direction    of    the   mental 

processes  as  shown  in  disorders  of  the  attention  48 

III.  Disturbances  of  sensation,  including  hallucinations   51 

IV.  Disturbances  of  consciousness    67 

V.  Disturbances  in  the  functions  of  association.     Interference 

with  the  expression  of  connected  thought.     Anomalies  of 

memory.     Disturbances  in  orientation   73 

VI.  Disturbances  in  the  volitional  processes   87 

VII.  Disturbances  in  the  emotional  reactions 108 

VIII.  Anomalies   of  conduct   with   especial   reference  to   the   so- 
called  moral  insanity   119 

CHAPTER    IV 
The    method   of   examination   of   patients,    including   examina- 
tion of  the  cerebrospinal  fluid 127 

CHAPTER   V 
The  treatment  of  cases  of  alienation 146 

CHAPTER    VI 

The  modern  hospital  for  the  insane 167 

vii 


viii  CONTENTS 

CHAPTER   VII  PAGE 

General  causes  of  insanity. 

General  considerations.  Heredity.  Environment.  Sex.  Age. 
Occupation.  Education.  Suggestion  and  imitation.  Fatigue. 
Trauma.  Marriage.  Pregnancy  and  parturition.  Intoxications. 
Diseases  of  the  internal  viscera.  Brain  diseases.  Nervous  dis- 
eases     178 

CHAPTER   VIII 
The  principles  concerned  in  the  provisional  clinical  grouping  of 

mental  diseases  225 

CHAPTER    IX 
Mental  anomalies  the  result  of  defective  development  of  the 
central  nervous  system. 
Idiocy.     Imbecility.     Mental  debility   230 

CHAPTER    X 
Psychoses  which  are  probably  in  part  the  result  of  autointoxica- 
tion. 
Febrile   deliria,    including  pre-febrile   and  post-febrile  psychoses. 
Acute  confusional  or  delirious  states.    Acute  collapse  delirium. 
Subacute   delirious    or    confusional    states   (amentia).      Korsa- 
kow's  syndrome  254 

CHAPTER   XI 
Psychoses  the  result  of  chronic  intoxications. 

Alcoholism,  including  transitory  disturbances  of  consciousness. 
Delirium  tremens.  Acute  alcoholic  hallucinosis.  Morphinism, 
cocainism,  etc 285 

CHAPTER   XII 
Psychoses   associated  with   imperfect  functioning  of  the  thy- 
roid GLAND. 
Myxedematous  and  cretinous  insanity   326 

CHAPTER   XIII 
The  manic-depressive  group. 

States  of  excitement,  depression,  mixed  and  paranoioid  states  . . .  336 


CONTENTS  ix 

CHAPTER   XIV  PAGE 

The  dementia  precox  group  372 

CHAPTER   XV 
The  dementia  paralytica  group  413 

CHAPTER    XVI 
The  epilepsy  group  473 

CHAPTER   XVII 
The  hysteria  group    494 

CHAPTER   XVIII 
Neurasthenic  and  psychasthenic  states   516 

CHAPTER   XIX 
Psychoses  associated  with  organic  disease  of  the  central  ner- 
vous  SYSTEM. 
Brain  tumors.     Arteriosclerosis.     Cerebral  hemorrhage.     Throm- 
bosis.    Multiple  sclerosis.     Syphilis,  etc 544 

CHAPTER   XX 
The  paranoia  group  564 

CHAPTER   XXI 
The  senile  group.    Psychoses  connected  with  the  period  of  senile 
involution 
States  of  excitement  and  depression.     Paranoioid  states.     Senile 
dementia    575 


ILLUSTRATIONS 


PAGE 

Handwriting  of  a  patient  suffering  from  dementia  praecox,  illustrating 

her  interpretation  of  her  changed  organic  sensations., 33,34,35 

Diagrams    illustrating   consanguinity   as   an   etiological    factor   in   the 

causation  of  insanity 187 

Plate  I.     Photomicrograph  of  a  ganglion  cell   260 

Plate  II.    Photomicrograph  of  a  normal  Betz  cell 260 

Plate  III.     Photomicrograph  of  a  fever  cell   260 

Plate  IV.     Photomicrograph  of  fever  cells   260 

Plate     V.     Photomicrograph  of  a  pyramidal  cell   (Bethe  stain) 260 

Plate  VI.     Photograph  of  a  patient  in  a  confusional  state  268 

Handwriting  of  a  patient  suffering  from  acute  alcoholic  halluci- 
nosis, showing  his  interpretation  of  his  changed  organic  sensa- 
tions    301,  302,  303 

Chart  illustrating  the  influence  of  position  upon  the  blood-pressure  in 

a  case  of  manic-depressive  insanity   345 

Plate  VII.     Chart  showing  temperature,  pulse,  and  respiration  curves 

in  a  case  of  manic-depressive  insanity  346 

Charts  illustrating  schematically  the  course  of  cases  of  manic-depres- 
sive insanity    347,  348 

Chart  showing  periodic  forms  of  manic-depressive  insanity 361 

Chart  showing  the  course  in  cases  of  manic-depressive  insanity 362 

Weight  chart  in  a  case  of  manic-depressive  insanity 367 

Plate  VIII.     Showing  a  maniacal  patient  in  the  continuous  bath  370 

Plate  IX.  Drawing  made  by  a  patient  during  a  period  of  mild  cata- 
tonic  excitement    386 

Handwriting    illustrating    irrelevant    replies    in    a    case    of    dementia 

praecox 389 

Plate  X.     Photograph  illustrative  of  cerea  flexibilitas   392 

Chart    illustrating    schematically    the    course    of    a    case    of    dementia 

prsecox  403 

Chart  illustrating  the  incidence  of  general  paralysis  in  women  414 

Chart  illustrating  the  incidence  of  general  paralysis  in  men 415 

xi 


xii  ILLUSTRATIONS 

PAGE 

Specimen  of  handwriting  of  a  patient  suffering  from  dementia  para- 
lytica    432 

Plate  XL     Photomicrograph  showing  thickening  of  pia-arachnoid  and 

adhesions  between  pia-arachnoid  and  cortex  in  a  case  of  paresis.  .  462 

Plate  XII.  Drawings  showing  the  normal  distribution  of  medullated 
fibres  in  the  different  cortical  regions   463 

Plate  XIII.  Drawings  of  sections  of  the  cortex  from  a  normal  case 
and  from  a  case  of  paresis  (stained  with  the  Bielschowsky  fibril 
stain)   " 464 

Plate  XIV.  Drawings  of  a  normal  giant  cell  and  a  giant  cell  from 
a  case  of  paresis  (stained  with  the  Bielschowsky  fibril  stain)....  464 

Plate   XV.      Photomicrograph   of   giant   spider-cells    from   a   case   of 

paresis   466 

Plate  XVI.  Drawing  showing  an  increase  in  the  number  of  giant 
spider-cells  in  the  cortex  of  a  case  of  paresis  467 

Plate  XVII.     Drawing  showing  a  blood-vessel  from  the  cortex  in  a 

case  of  paresis   468 

Plate  XVIII.    Table  giving  points  for  the  differential  diagnosis  of  the 

pathological  changes  in  paresis  from  those  of  other  conditions...  470 

Plate  XIX.     Drawing  showing  rod  cells  from  a  case  of  paresis  471 

Plate  XX.     Photograph  of  a  patient  with  senile  melancholia  578 

Chart  showing  ages  of  incidence  in  cases  of  senile  dementia 594 


PSYCHIATRY 


CHAPTER    I 

THE     IMPORTANCE,     SCOPE,     AND     METHODS     OF     MODERN 
PSYCHIATRY  * 

Psychiatry  is  a  branch  of  general  medicine.  One  of  its 
objects  is  to  investigate  the  causes,  course,  and  termination  of 
those  diseases  whose  chief  symptoms  are  characterized  by 
anomalies  in  the  so-called  mental  processes.  The  ultimate  aim 
of  these  studies  should  be,  first  and  foremost,  to  find  and  then 
to  apply  the  means  best  adapted  to  promote  normal  thinking; 
for  the  actual  cure  of  cases  of  alienation  is  a  matter  of  sec- 
ondary importance  in  comparison  with  the  discovery  of  methods 
of  preventing  its  spread. 

In  view  of  the  increasing  amount  of  interest  taken  by  the 
public  in  all  matters  affecting  its  general  welfare,  it  would 
hardly  seem  necessary  to  make  a  special  plea  for  the  granting  of 
opportunities  for  study  and  investigation  to  those  whose  chief 
interest  is  to  ascertain  the  surest  and  best  means  of  promoting 
rational  thought  and  action.  If  Norman  Lockyer's  dictum  be 
true,  that  "  a  struggle  has  begun  in  which  science  and  brains  are 
to  take  the  place  of  sword  and  sinews,"  is  it  not  desirable  that 

1  Cowles,  Edward :  Advanced  Professional  Work  in  Hospitals  for  the 
Insane.  Am.  Journ.  Insan.,  vol.  lx,  1898.  Gaupp,  R. :  Ueber  die  Gren- 
zen  psychiatrischer  Erkenntniss.  Centralbl.  f.  Nervenheilk.  u.  Psych.,  Jan- 
uar,  1903.  Bawden,  H.  H. :  Recent  Tendencies  in  the  Theory  of  the  Psy- 
chical and  Physical.  The  Psychological  Bulletin,  Literary  Section  of 
Psychol.  Review,  March  15,  1904.  Meyer,  Adolf:  A  Few  Trends  in 
Modern  Psychiatry.  Hoch,  August:  A  Review  of  Psychological  and 
Physiological  Experiments  done  in  Connection  with  the  Study  of  Mental 
Diseases.  The  Psychological  Bulletin  (Psycholog.  Review),  vol.  i,  Nos.  7 
and  8,  June  15,  1904. 


2  PSYCHIATRY 

some  concerted  and  well-directed  effort  be  made  to  find  out  the 
most  efficacious  way  of  increasing  the  brain  power  of  the 
nation?  If  the  question  of  the  mental  health  of  a  community 
is  one  of  vital  importance,  how  long  will  the  investigations 
relating  to  its  preservation  be  carried  on  under  such  discour- 
aging conditions  as  now  exist  in  this  country  ?  With  the  rapid 
growth  of  modern  civilization  the  duties  of  the  alienist  are 
every  day  becoming  more  arduous  and  complex ;  and  yet  at  the 
beginning  of  the  present  century,  particularly  in  the  United 
States  and  England,  he  finds  himself  poorly  equipped  to  grapple 
with  the  problems  forced  upon  him  not  only  in  his  routine  prac- 
tice, but  also  by  the  State  and  by  society  at  large.  What  is 
insanity?  How  may  the  ravages  of  the  scourge  be  lessened? 
How  far  are  individuals  responsible  for  their  actions?  These 
and  other  problems  of  equally  grave  import,  touching  the  very 
foundations  of  the  social  structure,  are  daily  propounded.  But 
that  in  reality  the  public  are  wholly  indifferent  as  to  the  manner 
in  which  these  questions  are  answered  is  clearly  proved  by  the 
fact  that  no  suitable  provision  has  yet  been  made  in  this  country 
for  giving  instruction  in  psychiatry,  and  that  serious  investiga- 
tions concerning  the  nature  of  mental  diseases  have  scarcely 
been  begun.  Nor  does  it  appear  logical  that  in  the  face  of  this 
lamentable  state  of  affairs  the  opinion  of  the  so-called  expert 
on  insanity  is  daily  sought  for  and  forms  the  basis  upon  which 
even  the  issues  of  life  and  death  are  decided.  Fortunate  would 
be  the  community  in  which  there  was  a  fully  equipped  and  well- 
organized  psychiatrical  clinic  under  the  control  of  a  university 
and  dedicated  to  the  solution  of  these  and  similar  problems. 
The  mere  presence  of  such  an  institution  would  indicate  that 
people  were  as  much  interested  in  endeavoring  to  increase  the 
public  sanity  as  they  are  in  the  results  of  exploration  in  the 
uttermost  parts  of  the  earth  or  in  the  discovery  of  a  new  star. 
There  is  no  department  of  medicine  in  which  the  investi- 
gator needs  to  be  in  more  intimate  touch  with  the  advances  of 
modern  science  than  in  psychiatry.  The  problems  to  be  solved 
by  it  are  mainly  of  general,  not  special,  interest.  It  not  only 
forms  a  branch  of  general  medicine,  but  should  be  classed  with 


SCOPE   AND    METHODS  3 

other  biological  studies.  Science  has  demonstrated  that  the 
anomalies  in  thought,  action,  volition,  and  emotion,  popularly 
referred  to  as  forms  of  insanity,  are  the  expression  of  a  disor- 
dered functioning  of  the  central  nervous  system.  Gradually  we 
are  awakening  to  an  appreciation  of  the  fact  that  the  same  gen- 
eral methods  of  investigation  that  are  applicable  in  the  study  of 
all  biological  sciences  may  be  successfully  adopted  in  attacking 
the  problems  connected  with  mental  diseases. 

Let  us  consider  very  briefly  the  methods  which  the  alienist 
may  employ  in  dealing  with  psychic  phenomena.  The  problems 
to  be  solved  can  be  approached  from  several  stand-points  which 
for  the  sake  of  convenience  can  be  described  as  psychological, 
clinical,  chemico-physical,  and  anatomico-pathological.  A  word 
may  here  be  said  regarding  the  attitude  of  the  alienist  towards 
the  study  of  mental  phenomena  or  the  functions  of  the  cerebral 
cortex.  Instead  of  contenting  himself  with  a  naive  psychology 
founded  upon  theory  and  speculation,  he  has  been  taught  to 
rely  upon  the  basis  of  steady,  painstaking  observation,  sub- 
stantiating his  results  whenever  possible  by  experiment.  And 
by  these  methods  alone  will  it  become  possible  to  attain  a  com- 
prehensive rational  understanding  of  the  nature  of  insanity. 
The  point  of  view  of  the  modern  physiologist,  that  organic 
processes  are  referable  to  physico-chemical  changes,  offers  an- 
other vantage  ground,  since  physiology  also  teaches  that  ma- 
terial changes  in  any  organ  give  rise  to  disorders  of  function. 
The  brain  is  no  exception  to  this  rule.  Changes  in  conscious- 
ness, anomalies  in  the  emotional  life,  impairment  of  volition, 
are  merely  expressions  of  a  disturbance  in  equilibrium  of  the 
functions  of  the  brain.  In  this  country,  particularly,  the  alienist 
is  singularly  indebted  to  the  physiologist  and  to  the  psycholo- 
gist, not  only  for  keeping  alive  and  stimulating  interest  in  the 
study  of  mental  phenomena,  but  also  for  valuable  contributions 
that  have  been  made  by  both  to  our  knowledge  of  the  functions 
of  the  central  nervous  system.  So  little  is  known,  so  much  still 
remains  to  be  found  out,  and  the  speculative  tendency  in  certain 
quarters  is  so  strong,  that  the  temptation  to  substitute  theory 
for  observation  and  experiment  has  to  be  met  and  resisted  at 


4  PSYCHIATRY 

every  turn.  The  relation  of  body  and  mind  is  still  an  enticing 
theme  for  the  philosopher,  but  to  spend  valuable  time  in  theoriz- 
ing as  to  the  manner  in  which  the  ultimate  solution  of  this 
problem  will  be  effected  belongs  only  to  those  who  live  in  a 
realm  that  is  far  afield  from  the  path  of  the  clinician.  New 
points  of  view  are  always  desirable,  if  they  ultimately  lead  to 
the  discovery  of  additional  facts ;  but  psychiatry  cannot  afford 
to  build  upon  shifting  sands.  The  theories  of  psycho-physic 
parallelism  and  of  neo-vitalism  may  afford  useful  working 
hypotheses  to  many  investigators,  but  their  adoption  as  philo- 
sophical creeds  should  be  a  matter  of  no  concern  to  the  alienist. 
The  attempt  to  establish  a  "  psychological  basis"  for  the  study 
of  mental  disease  is  quite  as  undesirable  as  would  be  the  attempt 
to  limit  clinical  medicine  to  the  mere  study  of  symptoms.  The 
psychological  method  is  a  useful  aid  to  investigation,  but  to 
consider  its  scope  and  methods  as  the  end-all  of  modern  psy- 
chiatry shows  no  appreciation  of  the  advances  that  have  already 
been  made.  Great  as  has  been  the  stimulus  derived  from  psy- 
chological studies,  the  alienist  fully  appreciates  that  his  line  of 
investigation  differs  essentially  from  that  of  the  psychologist. 

But  before  pointing  out  more  in  detail  the  positive  advan- 
tages derived  from  the  new  psychology  a  word  of  caution  is 
necessary.  The  facts  derived  from  observation  and  experi- 
ment have  thwarted  the  attempts  of  those  who  have  tried  to 
transform  the  useful  working  hypotheses  expressed  in  the 
theory  of  psycho-physic  parallelism  into  dogmas.  Even  those 
who  were  formerly  the  most  ardent  supporters  of  this  doctrine 
are  now  willing  to  admit  that,  while  the  parallelism  may  hold 
in  the  case  of  the  simpler  sensations,  it  cannot  be  applied  to  the 
more  complicated  psychic  phenomena.  Even  in  the  analysis  of 
the  simpler  mental  phenomena  2  it  is  impossible  to  correlate  the 
so-called  mental  and  physical  events.  In  all  the  cerebral  pro- 
cesses, from  the  simplest  sensations  to  the  most  complex  psychic 
phenomena,  there  is  a  series  of  physico-chemical  changes  that 

2  V.    Kries :     Ueber   die  materiellen    Grundlagen   der    Bewusstseinser- 
scheinungen,  1901. 


SCOPE    AND    METHODS      ,  5 

take  place,  and  these,  so  far  as  is  known,  have  no  immediate 
correlates  in  the  mental  sphere.  A  series  of  ether  vibrations 
strike  the  ear  and  the  individual  may  become  conscious  of  a 
musical  note.  How  is  each  event  in  this  physical  chain  to  be 
correlated  with  those  comprising  the  psychic  phenomenon? 
And,  in  fact,  do  not  the  teachings  of  modern  science  demonstrate 
the  futility  of  such  an  attempt?  According  to  the  psycho- 
physical theory  the  individual  events  in  one  place  are  not  con- 
trasted with  those  in  the  other,  but  what  is  actually  attempted 
is  the  establishment  of  a  parallelism  between  a  whole  series  of 
events  on  the  physical  side  with  those  in  the  mental  sphere. 

But  it  may  be  asked,  Who  shall  determine  exactly  the  two 
series  of  events  that  are  to  be  contrasted  ?  What  is  to  be  called 
physical  and  what  mental;  and  what  censor  shall  decide  the 
question  for  us  ?  The  careful  analysis  of  the  cerebral  functions 
has  resulted  in  the  destruction  of  the  artificial  barriers  that  were 
supposed  to  separate  them  from  each  other.  The  differences 
of  gradation  but  not  of  quality  are  recognized.  The  power  of 
discrimination  between  violet  and  yellow,  heat  and  cold,  plea- 
sure and  pain,  represents  to  each  sentient  individual  important 
distinctions,  but  by  what  right  do  we  assume  that  in  the  final 
analysis  these  differences  are  not  referable  to  physical  processes 
that  vary  only  in  degree  and  intensity  ?  For  all  that  we  know 
to  the  contrary  there  are  no  abrupt  divisions  or  chasms  to  be 
crossed.  The  cerebral  processes  vary,  but  they  do  so  by  de- 
grees, by  shading  off  into  each  other  without  gap  and  without 
break  in  continuity. 

It  would  be  superfluous  to  emphasize  the  necessity  of 
far  more  active  cooperation  in  America  between  psychologist 
and  psychiatrist  were  there  not  abundant  evidence  of  the  lack 
of  communism  of  interests.  Two  facts  have  contributed  to 
this  unfortunate  condition.  In  the  first  place,  too  many  stu- 
dents of  normal  mental  phenomena  start  with  philosophical 
speculation  and  make  exact  observation  and  the  recording 
of  facts  of  merely  secondary  importance.  This  attitude  in  a 
measure  accounts  for  the  widespread  and  not  unjustifiable 
scepticism  abroad  as  to  the  true  merit  of  many  of  the  so-called 


6  PSYCHIATRY 

psychological  investigations.  And  again,  when  a  recognized 
leader  in  the  modern  school  of  psychology  has  actually  admitted 
defeat  and  declared  that  his  specialty  never  can  become  a 
science,  is  it  to  be  expected  that  the  wares  he  offers  for  sale  are 
to  be  taken  at  more  than  their  appraised  value?  But,  happily, 
although  he  may  have  succeeded  in  demonstrating  the  ineffi- 
ciency of  his  own  methods,  he  has  failed  signally  in  the  attempt 
to  prove  that  all  others  are  equally  untrustworthy.  More  hopeful 
investigators — and,  fortunately,  they  represent  the  large  major- 
ity of  psychologists — still  have  faith  in  the  efficacy  of  patient 
and  well-directed  observation.  The  end  is  not  yet  in  view,  but 
a  bright  and  brilliant  page  is  being  written,  and  even  in  the  face 
of  what  seem  to  be  insuperable  difficulties  the  investigator,  in 
the  light  of  the  advances  that  have  been  made  since  Herbart's 
day,  finds  reason  to  take  courage  and  begin  the  attack  anew. 
Observation,  whether  it  be  introspective  in  character  or  be 
applied  to  the  study  of  mental  phenomena  noted  in  others,  is 
being  carried  on  with  more  rigorous  exactitude  than  ever  be- 
fore. This  is  still  the  period  of  critical  analysis.  The  period 
of  synthesis  will  come  as  soon  as  the  methods  of  introspection, 
of  observation  of  the  normal  and  abnormal  mental  processes, 
and  of  experiment  stand  the  crucial  tests  applied  to  them. 

A  few  important  facts  have  been  unearthed  that  have  given 
us  new  points  of  view,  and  as  a  consequence  of  this  extension  of 
the  horizon  many  of  the  immediate  clinical  problems  have 
become  less  complex  as  the  old  riddles  have  been  re-stated  in  the 
language  of  the  physiologist,  thus  rendering  an  attack  with 
promise  of  success  no  longer  an  improbability.  In  the  analysis 
of  sensations  Mach  3  and  others  have  at  least  formulated  work- 
ing hypotheses  of  great  practical  value.  Furthermore,  it  has 
been  demonstrated  that  the  various  muscle,  joint,  and  complex 
organic  sensations  not  only  play  an  important  role  in  the  physi- 
ology of  sensibility,  but  are  also  intimately  related  to  the 
higher  mental  processes.  Within  the  last  two  decades  the  con- 
stantly increasing  number  of  publications  devoted  to  studies 

8  Die  Analyse  der  Empfindung,  Jena,  1902. 


SCOPE    AND    METHODS  7 

in  psycho-pathology  have  given  a  new  impetus  to  clinical 
psychiatry.  These  and  similar  studies  have  shown  that  the 
methods  used  in  the  laboratory  to  investigate  the  problems  of 
normal  brain  physiology  necessitate  modification  before  they 
can  be  adapted  to  meet  the  conditions  in  the  ward,  and  as  a  re- 
sult attempts  are  in  progress  to  select  for  investigation  methods 
as  simple  as  possible  which  may  be  applied  to  the  study  of  indi- 
vidual cases  by  the  clinician  at  the  bedside.  Psycho-pathology 
does  not  begin  and  end  merely  by  measuring  the  promptness  of 
reactions;  its  chief  service  has  been  in  an  analysis  of  the 
attention,  in  the  study  of  the  character  of  the  individual  reac- 
tions, of  the  anomalies  of  connected  thought,  and  in  investi- 
gating the  sharpness  and  correctness,  under  varying  conditions, 
of  individual  judgment.  One  result  of  all  this  study  has  been 
that  more  or  less  abstract  terms  can  now  be  replaced  by  simpler 
expressions  which  greatly  facilitate  the  formulation  of  the  prob- 
lems to  be  solved.  Take,  for  example,  the  analysis  of  the  mental 
symptoms  of  fatigue.  In  this  connection  it  has  been  shown  that 
the  symptomatology  of  fatigue  can  not  be  expressed  in  one  con- 
crete and  homogeneous  term,  but  represents  an  aggregate  of 
symptoms.  Furthermore,  we  know  that  the  fluctuations  of  the 
mental  functions  in  different  persons  vary  not  only  as  conditions 
change,  but  at  different  times  of  the  day  in  the  same  individual.4 
The  investigations  that  have  for  their  aim  the  determina- 
tion of  mental  capabilities  and  individual  variations  deal  with 
problems  of  vital  significance,  and  a  word  may  be  said  in  refer- 
ence to  the  important  practical  bearing  of  these  studies.  As 
will  be  seen  later,  the  exaggeration  of  personal  reactions  or 
idiosyncrasies  plays  no  small  role  in  the  pathogenesis  of  insan- 
ity. A  comprehension  of  the  evolution  of  such  disease  pro- 
cesses, therefore,  calls  for  a  more  or  less  accurate  knowledge 
of  mental  traits  and  idiosyncrasies.  Before  he  can  expect  to 
recognize  an  incipient  mental  defect  the  physician  must  be  able 
to  form  at  least  an  approximate  estimate  of  what  is  normal,  and 


*  Finzi,    J. :     Die    normalen    Schwankungen    der    Seelenthatigkeiten. 
Uebersetzt  von  Jentsch,  Wiesbaden,  1903. 


8  PSYCHIATRY 

any  attempt  to  do  this  necessitates  the  careful  study  of  cases 
and  a  minute  and  scrupulously  exact  differentiation  of  symp- 
toms. In  this  way  alone  will  it  be  possible  to  determine  the 
standards  of  measurements  by  which  the  mental  capacity,  the 
intensity  or  incongruity  of  emotional  reactions,  the  limita- 
tions of  the  volitional  processes,  and  other  conditions  can  be 
estimated.  Undoubtedly  much  of  the  indifference  exhibited  by 
the  medical  public  to  the  study  of  psychiatry  has  arisen  because 
alienists  have  hitherto  failed  to  enlist  the  sympathy  of  intelli- 
gent physicians,  inasmuch  as  they  have  not  demonstrated  with 
sufficient  care  the  tangible  visible  reactions  in  cases  of  aliena- 
tion, and  the  possibility  of  provisionally  grouping  them  accord- 
ing to  their  intensity  in  some  sort  of  orderly  fashion.  Most 
of  these  phenomena  are  as  apparent  as  are  the  physical  symp- 
toms of  cardiac  or  pulmonary  disease,  and  it  is  no  less  possible 
to  obtain  a  clue  as  to  what  constitutes  the  normal  functioning 
of  the  brain  than  to  detect  impairment  of  the  respiratory  or 
cardiac  functions.  Granting  the  truth  of  this  affirmation, — 
and  it  is  one  that  may  be  tested  by  observation, — the  immediate 
need  of  prosecuting  these  investigations  with  renewed  vigor 
at  once  becomes  apparent. 

One  or  two  concrete  examples  will  be  sufficient  to  demon- 
strate the  demand  for  such  a  procedure.  The  opinion  of  an 
expert  is  sought  for  in  examining  a  new  recruit  who  is  desirous 
of  entering  the  ranks  of  the  army  or  navy ;  and  to-day  the  uni- 
versities have  physical  directors  to  examine  into  and  pass  upon 
the  physical  condition  of  students  before  they  are  allowed  to 
compete  in  inter-collegiate  sports.  And  yet  at  the  same  time  a 
heterogeneous  mass  of  humanity,  without  any  form  of  selection 
and  utterly  regardless  of  its  fitness,  is  driven  through  a  so-called 
education.  Society  at  large  must  sooner  or  later  awaken  to  the 
realization  that  the  indiscriminate  education  of  the  masses  can 
not  be  too  strongly  condemned,  for  excessive  demands  on  the 
brain  power  of  a  community  must  ultimately  lower  not  only  the 
intellectual,  but  also  the  moral  standards.  Even  with  the  crude 
and  imperfect  methods  now  used  by  the  alienist,  if  the  oppor- 
tunity were  given  to  him  to  apply  his  tests,  it  would  be  possible 


SCOPE    AND    METHODS  9 

greatly  to  reduce  the  numbers  of  those  who  are  seriously  injured 
mentally  and  morally  by  a  schooling  ill  adapted  to  their  indi- 
vidual needs  and  necessities.  Every  one  admits  that  it  is  the 
duty  of  the  physician  to  warn  those  with  weak  hearts  or  lungs 
not  to  overtax  those  organs.  Is  it  not  equally  important  that 
the  mental  welfare  of  a  community  be  safeguarded?  Only 
some  men  are  born  to  be  educated;  how  many  more,  unfor- 
tunately, have  thrust  upon  them  an  education  which  is  disas- 
trous not  only  to  themselves,  but  also  to  the  community  at 
large!  To  prevent  the  sins  of  over-educated  fathers  and 
mothers  from  being  visited  upon  the  children  unto  the  third  and 
fourth  generation  is  a  problem  of  great  sociological  as  well  as 
economic  importance  to  the  state.  The  sudden  expansion  of 
mental  powers  may  be  quite  as  unfortunate  as  the  sudden  acqui- 
sition of  riches,  and  the  community  that  heedlessly  imposes 
mental  tasks  indiscriminately  upon  the  children  in  its  public 
schools  adds  greatly  to  the  list,  already  appalling  in  length,  of 
those  who  overtax  the  capacities  of  hospitals  for  the  insane. 

Those  who  are  familiar  with  the  trend  of  modern  psy- 
chiatry do  not  need  this  reminder  of  the  fact  that  the  work  of 
the  alienist  has  an  important  bearing  on  problems  of  the  highest 
ethical  importance.  Not  only  is  the  alienist  concerned  in  the 
attempt  to  throw  light  upon  the  nature  and  genesis  of  insanity, 
but  as  these  investigations  necessitate  on  his  part  the  careful 
analysis  of  the  higher  cerebral  faculties  and  the  determination 
of  the  source  of  motives  for  action,  his  work  leads  him  to  the 
consideration  of  all  problems  connected  with  the  conduct  of  his 
fellow-creatures.  Duprat 5  has  emphasized  the  fact  that  "  the 
doctor-philosopher"  of  to-day,  in  following  men  like  Charcot, 
Ribot,  and  Janet,  has  introduced  into  psychology  an  entirely 
new  spirit.  These  authors  have  shown  that  the  impulses  and 
vagaries  of  conduct  in  the  person  affected  with  nervous  or 
mental  disease  are  only  accentuations  of  traits  common  to  each 
individual.    As  the  result  of  this  and  similar  investigations  his 


8  Duprat,  G.  L. :   Morals.    A  Treatise  on  the  Psycho-sociological  Bases 
of  Ethics.     Transl.  by  W.  J.  Greenstreet.    New  York,  1903. 


10  PSYCHIATRY 

special  field  has  so  broadened  that  the  alienist  finds  to-day  that 
he  has  entered  the  sacred  precincts  once  occupied  solely  by  the 
metaphysician  and  the  philosopher.  The  doctrine  that  all  pro- 
cesses which  disturb  or  curtail  the  functions  of  the  nervous 
system  are  followed  not  only  by  defects  in  connected  thought 
and  rational  action,  but  with  equal  certainty  by  anomalies  of 
conduct  in  the  ethical  and  moral  spheres,  is  merely  a  statement 
of  facts  that  are  self-evident  to  those  whose  eyes  are  trained 
to  observe.  Those  who  would  lead  the  blind  must  themselves 
know  how  to  walk ;  they  must  be  sure  of  their  own  sight  and 
know  whither  they  are  going.  Theories  worked  out  in  the 
cloister,  preconceived  ideas  of  what  ought  to  be,  the  invocation 
of  the  categorical  imperative,  can  no  longer  supply  even  tenta- 
tive explanations  of  the  cause  and  motives  of  our  actions. 
There  is  a  preventive  morality  just  as  there  is  a  preventive 
medicine,  and  he  who  would  understand  the  former  must  know 
something  about  impulses,  imperative  ideas,  inhibition,  psycho- 
motor excitement,  and  suggestion.  Conduct  is  the  measure  of 
the  functional  capacity  of  the  central  nervous  system ;  and  there 
may  be  psycho-motor  excitement  in  the  carrying  out  of  the  most 
complicated  as  there  is  in  the  execution  of  the  simplest  acts,  such 
as  raising  an  arm  or  taking  a  step.  Surely  he  who  is  capable 
of  interpreting  the  simpler  phenomena,  without  making  preten- 
tious claims,  may  rightly  affirm  that  he  is  in  a  better  position 
than  the  mere  doctrinaire  to  study  the  problems  of  conduct. 

Not  only  has  it  become  possible  by  simple  clinical  study  to 
analyze  many  of  the  more  complex  volitional  processes,  but 
some  of  the  fundamental  facts  observed  have  been  substantiated 
by  experiment.  The  various  abnormal  psychic  states,  that  are 
due  to  the  effects  of  alcohol,  morphin,  caffein,  the  bromides, 
and  other  poisons  upon  the  mental  processes,  have  been  studied 
and,  although  the  results  show  considerable  discrepancies,  a 
sufficient  number  of  data  have  already  been  brought  to  light  to 
justify  further  investigations  in  this  field.6    Hoch's  studies,  be- 


8  Weygandt,   W. :    Die   Forschungsrichtung   der   Psychologischen   Ar- 
beiten.     Centralbl.  f.  Nervenheilk.  u.  Psych.,  1903,  Nr.  156,  158. 


SCOPE    AND    METHODS  II 

gun  in  Kraepelin's  laboratory  and  continued  in  this  country, 
would  have  received  far  wider  recognition  and  would  have 
served  to  arouse  the  interest  of  alienists  in  America  to  the  far- 
reaching  character  of  such  investigations  had  there  been  a  more 
intelligent  appreciation  of  the  need  of  accurate  and  timely  ob- 
servation along  these  lines.  Not  only  have  the  more  elementary 
mental  processes  been  a  subject  of  careful  study,  but  the  emo- 
tions, the  volitional  processes,  the  powers  of  discrimination  and 
judgment,  and  the  complex  personality  have  been  shown  to  be 
composite,  not  single  functions,  and  "  functional  psychology 
has  at  last  succeeded  faculty  psychology."  7 

If  now  we  turn  to  the  consideration  of  what  the  application 
of  these  psychological  methods  to  the  study  of  patients  has  ac- 
complished, it  will  be  found,  in  the  first  place,  that  a  fertile  field 
is  at  once  opened  to  investigators.  In  a  clinical  psychology  such 
as  that  exemplified  in  the  studies  of  Wernicke  and  Ziehen  the 
advantages  and  disadvantages  of  this  method  readily  become 
apparent.  From  a  purely  practical  stand-point  alone  Wernicke's 
work  is  unique  and  deserves  the  attention  of  every  practical 
alienist.  Believing  as  he  does  that  the  time  is  not  yet  ripe  for 
broad  comprehensive  classifications,  Wernicke  attempts  merely 
to  analyze  accurately  the  individual  symptoms  in  different  dis- 
eases in  the  hope  that  some  additional  clue  may  ultimately  be 
obtained  as  to  the  etiology  and  genesis  of  a  given  disorder. 
Here  we  have  at  its  best  the  critical  analysis  of  symptoms,  and 
no  one  who  has  carefully  studied  Wernicke's  Psychiatry  can 
fail  to  appreciate  the  evident  genius  that  is  reflected  in  this 
method.  But  the  fact  that  the  analysis  of  cases  is  so  keen  and 
the  results  of  the  observations  are  presented  in  so  clear  and 
cogent  a  manner  renders  the  defects  of  a  symptomatologic 
grouping  all  the  more  obvious.  The  attempt  to  compare  the 
disturbances  in  the  psychic  functions  with  those  of  speech, 
although  from  a  psychological  stand-point  ingenious  and  one 
that  has  unquestionably  facilitated  the  clinical  study,  is  a 
method  of  investigation  that  can  not  by  itself  lead  the  alienist 

7  Baldwin,  J.  M. :     Mental  Development.     New  York,  1897. 


12  PSYCHIATRY 

to  the  goal  he  strives  for.  Descriptive  psychiatry  has  been 
singularly  enriched  by  this  narrative  of  cases  in  terms  that  have 
not  as  yet  had  a  specific  meaning  assigned  to  them,  but  other  no 
less  important  factors  have  not  been  treated  with  equal  con- 
sideration. The  method  employed  by  Wernicke  is  a  fulfilment 
of  a  hope  expressed  by  Kahlbaum  that  a  careful  analysis  and 
study  of  the  mental  phenomena  of  the  insane  would  ultimately 
give  birth  to  a  special  scientific  symptomatology,  the  immediate 
outcome  of  clinical  investigation  and  not  the  mere  adaptation  of 
current  psychological  theories  and  speculations.  No  better 
exemplification  of  the  good  that  may  be  accomplished  by  these 
refined  methods  of  analysis  can  be  brought  forward  than  by  a 
reference  to  the  studies  made  in  connection  with  the  various 
paranoiic  states.  In  the  light  of  recent  investigations  we  no 
longer  speak  of  primary  intellectual  defects,  as  if  the  intellect 
were  an  isolated  faculty,  or  compare  the  genesis  of  an  insane 
idea  to  the  birth  of  Minerva,  inasmuch  as  careful  observation 
has  shown  that  the  majority  can  be  traced  to  primary  changes 
in  organic  sensations,  anomalous  emotional  states,  and  dis- 
turbances in  the  complex  of  sensations  designated  collectively 
as  the  personality.  Head  8  has  shown  us  how  subtle  and  evan- 
escent may  be  these  early  changes  in  organic  consciousness,  and 
his  careful  observations  have  shown  that  the  genesis  of  the  most 
complex  mental  disturbances  may  ultimately  be  explained  by 
the  facts  brought  to  light  by  the  bedside  study  of  patients. 
Although  it  may  only  be  the  outline  sketch  that  he  has  as  yet 
given,  even  from  this  we  can  at  least  get  some  faint  idea  of  how 
the  intricate  paranoia-complex  develops  gradually  and  insidi- 
ously from  the  indefinite  apprehensiveness,  mild  suspiciousness, 
ill-defined  hallucinations  and  delusions  so  commonly  asso- 
ciated with  visceral  disease.  A  still  greater  refinement  of  the 
methods  employed,  a  greater  exhibition  of  patience,  a  little 
more  general  interest  in  careful  bedside  observation,  and  these 
apparently  illusive  problems  will  at  least  be  definitely  formu- 
lated. 


ease. 


1  Head,  Henry :    Certain  Mental  Changes  that  accompany  Visceral  Dis- 
Brain,  1901,  p.  345. 


SCOPE    AND    METHODS  13 

Another  excellent  example  of  what  may  be  accomplished 
by  these  methods  may  be  found  in  Bonhoeffer's  study  of  the 
alcoholic  psychoses.  Here  the  most  painstaking  methods  have 
been  adopted  in  the  analysis  of  the  mental  symptoms,  and  the 
character  of  the  reactions  obtained  in  individual  cases  has  been 
greatly  elucidated.  If  it  is  possible,  for  instance,  in  these  psy- 
choses of  toxic  origin  to  demonstrate  the  extent  and  nature  of 
the  anomalies  of  the  cerebral  functions,  we  may  in  the  end  get 
some  clue  as  to  the  manner  in  which  the  poison  acts. 

The  attitude  of  the  modern  alienist  was  clearly  indicated  by 
Kahlbaum  9  in  the  preface  to  his  classical  work  on  catatonia. 
The  insufficiency  of  the  psychologic  method  alone  was  clearly 
pointed  out,  whereas  the  danger  of  restricting  the  study  of  a 
disease  to  the  minute  analysis  of  symptoms  at  any  given  period 
was  shown  to  be  an  error  that  can  not  be  too  carefully  guarded 
against.  The  actual  advances  that  have  been  made  in  the  dif- 
ferentiation of  disease  groups  bear  testimony  to  the  necessity 
of  recognizing  this  principle.  The  most  prominent  example  is 
that  offered  by  the  investigations  that  culminated  in  the  gradual 
separation  of  the  dementia  paralytica  group  from  a  hetero- 
geneous mass  of  symptom-complexes.  This  division  was  made 
possible  by  the  study  not  merely  of  the  individual  mental  and 
physical  symptoms  at  one  period,  but  by  a  general  survey  of  the 
whole  course  of  the  disease.  The  attempt  to  apply  a  similar 
method  to  the  study  of  other  diseases  resulted  in  the  recognition 
by  the  French  of  the  circular  insanity  (folie  circulaire).  Iso- 
lated groups  of  symptoms  were  thus  shown  to  be  related  to 
others  that  on  the  surface  had  the  appearance  of  dissimilarity, 
and  Kahlbaum  was  able  to  define  the  catatonic  symptom-com- 
plex and  Hecker  to  elucidate  hebephrenia,  or  the  so-called 
adolescent  insanity. 

Among  the  apparently  radical  departures  that  have  been 
made  in  modern  psychiatry,  unquestionably  that  of  Kraepelin 
has  attracted  the  most  notice.     This  investigator  believed  that 


8  Kahlbaum,  Karl :     Abhandlungen  iiber  Psychische  Krankheiten.  Ka- 
tatonie.     Berlin,   1874. 


14 


PSYCHIATRY 


the  time  was  ripe  for  an  attempt  to  sketch  out  in  a  general  way 
certain  groups  which  might  eventually  prove  to  be  disease  enti- 
ties, and  numerous  observations  have  been  brought  to  light 
which  justify  this  position.  Alienists  had  already  emphasized 
the  necessity  of  studying  the  entire  course  of  a  disease  and  not 
merely  the  isolated  symptoms  of  a  given  period.  Similar  clini- 
cal pictures  were  known  to  occur  in  a  great  variety  of  disorders, 
and  the  analysis  of  these  individual  phenomena  by  themselves, 
without  regard  for  the  whole,  merely  impeded  progress. 
Granted  that  mental  diseases  are  not  essentially  different  from 
other  diseases  of  the  body,  no  less  regard  must  be  given  in 
psychiatry  to  the  course  and  prognosis  than  is  bestowed  upon 
them  in  other  maladies. 

Kraepelin's  departure  is,  however,  not  so  radical  as  many 
of  the  more  recent  critics  would  lead  us  to  believe.  His  attitude 
is  that  of  the  observer  who  finds  it  essential  to  success  that 
every  factor  connected  with  the  problem  in  question  should  be 
taken  into  account  and  given  its  due  valuation.  The  symp- 
tomatologic  grouping  may,  as  has  already  been  pointed  out,  be 
suggestive  in  many  ways,  but  no  definite  advance  can  be  made 
by  merely  refining  the  methods  for  the  study  of  symptoms. 
The  process  of  discrimination  which  led  to  the  formation  of  the 
two  groups  of  symptoms  under  the  heads  of  manic-depressive 
insanity  and  dementia  praecox  is  in  reality  an  excellent  example 
of  a  synthesis  carried  out  along  broad  and  comprehensive  lines. 

No  account  of  modern  psychiatry  would  be  complete  with- 
out some  mention  of  the  work  done  by  the  French  school,  par- 
ticularly that  of  Charcot  and  his  pupils,  in  differentiating  and 
describing  the  chief  characteristics  of  hysteria.  Here  again  the 
same  clinical  principle  has  been  applied  with  equally  successful 
results.  The  study  of  composite,  not  isolated,  pictures  has 
demonstrated  that  the  occurrence  of  hysterical  states  does  not 
necessarily  imply  the  existence  of  a  disease  entity.  To  compre- 
hend this  disorder  we  must  frequently  go  back  in  the  history  of 
the  individual  to  childhood  and  trace  the  whole  evolution  of  the 
disease  before  a  clear  and  comprehensive  idea  of  the  disorder 
becomes  possible.    Hysterical  traits  are  not  born  with  the  indi- 


SCOPE    AND    METHODS  15 

vidual,  but  in  all  probability  functional  defects  in  the  nervous 
system  exist  out  of  which  the  hysterical  character  develops 
whenever  there  is  sufficient  provocation.  Janet's  recent  con- 
ception of  psychasthenia  is  the  result  of  another  brilliant  study 
pregnant  with  suggestion  for  future  investigation,  although 
possibly  lacking  in  some  of  its  details  the  confirmation  of  facts 
to  be  obtained  only  after  a  more  protracted  period  of  clinical 
observation.  The  advancement  in  psychiatry  will  depend 
largely  upon  the  care  and  accuracy  with  which  individual  cases 
are  studied.  If  generalizations  are  to  be  successfully  made,  they 
must  be  based  upon  the  scrupulously  exact  analyses  of  all  the 
factors  concerned.  Fortunately  alienists  in  this  country  have  at 
last  broken  away  from  the  conventional  method  of  merely 
recording  groups  of  symptoms  without  attempting  to  assign  the 
proper  valuation  to  the  etiology,  course,  and  termination  of  the 
disease.  Persistent  and  exact  observation  in  the  ward  and  at 
the  bedside  is  fast  taking  the  place  of  the  haphazard  and  casuis- 
tic statistical  methods  that  so  long  threatened  to  stifle  the  in- 
tellectual life  of  those  who  were  engaged  in  collecting  these 
figures.  Even  yet,  in  order  to  gratify  the  morbid  curiosity  of 
the  public,  the  results  of  imperfect  observations  are  tabulated 
and  published  in  hospital  reports,  and  these  statistical  tidbits 
are  made  to  serve  as  the  basis  of  superficial  generalizations. 

The  present  is  the  time  in  which  to  perfect  the  methods  for 
the  careful  bedside  study  of  patients.  If  the  results  from  the 
laboratory  investigations  have  not  equalled  the  expectations  of 
those  who  would  reach  the  psychiatrical  Mecca  without  the 
toils  of  a  long  pilgrimage,  a  similar  high  standard  of  work  may 
be  profitably  adopted  by  the  clinician.  The  present  impedi- 
ments that  interfere  with  the  realization  of  this  advance  will  be 
discussed  when  we  come  to  speak  of  the  "  Modern  Hospital  for 
the  Insane."  The  remarkable  advances  that  have  been  made  in 
the  treatment  of  alienation,  as  well  as  the  relation  of  the  work 
of  the  pathologist  to  the  clinical  problems,  are  of  sufficient  im- 
portance to  become  the  subject  of  separate  chapters. 


CHAPTER    II 

THE    NATURE    OF    THE   DISEASE    PROCESS    IN    ALIENATION    AND 
ITS   RELATION   TO   THE   PATHOLOGICAL    CHANGES 

Any  attempt  to  discuss  the  nature  of  the  disease  process  in 
cases  of  mental  disorder  necessarily  brings  us  face  to  face  with 
a  number  of  problems  that  from  time  immemorial  have  per- 
plexed even  the  most  profound  thinkers.  While  it  is  a  fact  that 
in  many  cases  of  alienation  it  is  possible  to  demonstrate  certain 
morphological  changes  in  the  central  nervous  system,  the  exact 
relation  that  these  bear  to  the  mental  symptoms  of  the  disease 
can  not  even  be  conjectured.  In  spite  of  this  lack  of  continuity 
in  our  knowledge,  our  duty  in  regard  to  these  questions  is 
obvious.  Just  as  in  any  other  department  of  science  where  the 
realm  of  the  knowable  is  limited  in  comparison  with  that  of  the 
unknown,  we  must  hold  fast  to  the  little  that  we  actually  possess 
and  then  by  observation  and  experiment  endeavor  to  increase 
our  actual  store  of  facts.  Countless  investigators  in  every  de- 
partment of  science,  working  from  many  different  stand-points, 
are  attacking  the  problems  connected  with  the  relations  of 
structure  and  function.  But  so  many  ideas  and  new  rela- 
tionships are  being  constantly  proposed  that,  although  certain 
theories  may  from  time  to  time  be  accepted  as  supplying  a 
provisional  working  basis,  any  attempt  at  this  time  to  interpret 
and  correlate  all  the  different  views  and  opinions  would  be  a 
hopeless  task.  So  many  hypotheses  are  being  advanced  and  the 
tendency  to  indulge  in  speculation  is  still  so  prominent  a  char- 
acteristic of  the  human  mind  that  Mach's  warning  to  the  physi- 
cist to  beware  lest  he  "  out-philosophize  the  philosophers"  is 
equally  applicable  to  the  alienist  in  his  research  work. 

The  relation  of  structural  changes  to  disorders  of  func- 
tion is  still  a  matter  of  speculation.  Nor  is  this  uncertainty 
confined  to  the  central  nervous  system,  inasmuch  as  countless 
questions  of  a  similar  nature  are  arising  in  connection  with 

16 


NATURE    OF   ALIENATION  17 

every  organ  of  the  body.  Such  being  the  case,  it  would  not 
be  strange  if  the  exact  nature  of  the  disease  process  in  cases 
of  alienation  should  long  remain  in  doubt.  But,  despite  these 
serious  limitations,  workers  in  the  laboratory  and  clinic  should 
be  encouraged  by  the  fact  that  the  little  we  know  at  least  is 
sufficient  to  show  the  paths  along  which  the  alienist  must  pur- 
sue his  studies.  Experience  has  proved  that  the  process  causing 
the  functional  anomalies  is  a  general  one,  giving  rise  to  a  great 
complex  of  symptoms  and  ultimately  involving  more  or  less  of 
the  whole  personality.  The  correctness  of  this  view  is  further 
substantiated  if  we  pass  from  the  consideration  of  symptoms 
to  that  of  probable  causes.  Here  too  the  multiplicity  of  factors 
of  etiological  importance  at  once  becomes  apparent.  For  ex- 
ample, an  individual  has  an  attack  of  typhoid  fever  which  is 
followed  by  a  psychosis.  Is  the  fever  the  sole  exciting  agent  or 
are  other  provocative  factors  concerned?  The  latter  view  is 
undoubtedly  the  correct  one.  In  the  same  way  dementia  para- 
lytica is  not  looked  upon  merely  as  the  consequence  of  pro- 
longed over-indulgence  in  alcohol  or  of  a  specific  infection,  but 
the  individual  so  afflicted  is  regarded  as  having  been  in  all 
probability  "  half  born  a  paretic."  Although  definite  answers 
can  not  be  given  at  present  to  these  and  similar  questions,  at 
least  we  have  learned  to  recognize  the  important  fact  that  our 
investigations  of  these  problems  must  be  undertaken  from  a 
broad  and  comprehensive  stand-point.  What  are  especially 
needed  in  psychiatry  at  present  are  intelligent,  broad-minded 
clinicians  sufficiently  in  touch  with  the  methods  and  data  of 
modern  science  to  be  able  to  differentiate  between  these  com- 
plex problems  awaiting  solution  and  decide  which  of  them 
may  be  attacked  from  the  clinical  stand-point  and  which  had 
better  be  left  to  the  biologist  or  chemist. 

In  investigating  into  the  nature  of  the  process  in  cases  of 
alienation  we  are  naturally  led  to  inquire  whether  or  not  mental 
disorders  are  to  be  classed  as  diseases  of  the  brain.  There  can  be 
no  doubt  that,  if  we  view  them  purely  from  the  symptomato- 
logical  stand-point,  Wernicke  is  correct  in  affirming  that  mental 
disorders  are  essentially  diseases  of  the  brain,  not  localized  but 


18  PSYCHIATRY 

general  in  character.  In  one  sense  this  position  is  thoroughly 
justifiable  and  is  an  indication  that  genuine  advances  have  been 
made  in  psychiatry.  But  this  view  can  not  be  maintained  at 
present  without  some  qualification.  In  the  case  of  dementia 
paralytica  it  is  easy  to  demonstrate  a  series  of  more  or  less  spe- 
cific changes  in  the  central  nervous  system,  and  with  these 
changes  we  correlate  a  number  of  functional  modifications 
which  also,  when  grouped  together,  bear  a  specific  stamp.  It 
should  not  be  forgotten,  however,  that  evidence  adduced  from 
clinical  and  pathological  studies  seems  to  favor  the  current  view 
that  dementia  paralytica  is  the  result  of  a  toxic  condition, 
although  we  are  still  profoundly  ignorant  not  only  of  the  nature 
of  the  poison,  but  also  of  its  place  of  origin.  But  if  the  latter 
should  be  located  in  some  organ  outside  of  the  central  nervous 
system,  from  a  technical  stand-point  this  form  of  alienation 
can  not  be  regarded  as  being  purely  a  "  brain  disease."  An  even 
better  illustration  is  seen  in  the  study  of  mental  disturbances 
associated  with  myxcedema.  Here  it  is  known  that  the  anom- 
alies in  the  function  of  the  brain  depend  upon  disturbances  in 
the  thyroid  gland,  and  hence  it  would  be  quite  unfair  to  classify 
a  myxcedematous  insanity  as  a  disease  of  the  brain  alone. 

Although  the  facts  that  are  known  in  regard  to  the  his- 
tology and  pathology  of  the  central  nervous  system  are  so  few 
and  isolated  in  comparison  with  the  still  unexplored  territory, 
the  meagreness  of  the  practical  results  thus  far  obtained  by  no 
means  justifies  the  criticism  of  those  who  have  neither  sufficient 
patience  nor  training  to  enable  them  to  attain  a  broad  and  com- 
prehensive grasp  of  the  real  nature  of  the  problems  to  be  solved. 
The  many  defects  in  our  knowledge,  it  is  true,  serve  to  empha- 
size the  difficulties  with  which  the  alienist  is  confronted  in  his 
attempt  to  gain  a  more  comprehensive  knowledge  of  the  nature 
of  alienation,  but  they  need  not  deter  investigators  from  prose- 
cuting with  renewed  vigor  their  researches  in  the  realms  of 
physiology  and  anatomy.  A  few  years  ago  a  genuine  but  some- 
what premature  enthusiasm  led  not  a  few  workers  to  be- 
lieve that  the  new  methods  and  discoveries  in  the  histology 
and  pathology  of  the  central  nervous  system  promised  an  almost 


NATURE   OF   ALIENATION  19 

immediate  solution  of  many  of  the  problems  of  clinical  psychia- 
try. This  period  dates  from  the  work  of  Theodor  Meynert, 
of  Vienna,  whose  influence  was  felt  so  profoundly  by  alienists 
both  in  Europe  and  this  country.  Earlier  observers  had  al- 
ready directed  their  attention  to  the  nerve-cell,  and  in  a  gen- 
eral way  many  of  its  properties  and  histological  characteris- 
tics had  already  been  recognized.  Later  on  a  great  deal  of 
energy  was  directed  towards  disentangling  the  vast  complex 
of  fibres  which  were  found  to  exist  everywhere  in  the  central 
nervous  system,  many  of  the  workers  being  imbued  with  the 
idea  that  were  it  possible  to  bring  order  out  of  this  chaos 
great  immediate  benefit  could  be  derived  by  the  alienist  from 
these  studies  and  a  new  association  psychology  could  be 
founded  upon  an  anatomical  basis.  Unfortunately,  not  only 
were  these  hopes  not  realized  and  the  results  obtained  nega- 
tive, but,  on  the  other  hand,  the  habit  of  substituting  hypoth- 
eses based  upon  incomplete  anatomical  studies  for  clinical  in- 
vestigations in  some  measure  actually  delayed  even  the  proper 
formulation  of  the  really  essential  problems.  Nevertheless, 
genuine  advances  have  been  made  in  clinical  psychiatry,  thanks 
to  the  work  of  men  who  have  been  thoroughly  trained  them- 
selves and  who  have  sought  the  cooperation  of  the  pathologists. 
And  in  the  final  analysis  to-day  the  chief  inspiration  for  the 
clinician  must  come  from  those  who,  as  Pasteur  once  put  it, 
are  working  in  the  "  serene  peace"  of  their  laboratories. 

Great  as  are  the  inherent  difficulties  of  the  problems  that 
confront  the  alienist,  they  are  often  still  further  complicated  by 
unwise  attempts  to  interpret  immediately  clinical  symptoms  in 
the  light  of  the  facts  furnished  by  the  anatomist  and  pathologist. 
And  the  converse  is  equally  true.  Perhaps  the  most  striking 
example  of  this  error  is  to  be  found  in  the  attempt  to  assign  to 
the  anatomical  studies  of  Flechsig  an  immediate  physiological 
importance.  All  that  was  actually  demonstrated  by  these  in- 
vestigations was  that  the  development  of  medullation  in  the 
nerves  bears  some  general  relationship  to  the  appearance  of 
function,  but  it  has  by  no  means  been  established  that  the 
former  is  absolutely  essential  for  the  latter.    Indeed,  it  has  been 


20  PSYCHIATRY 

demonstrated  that  definite  nervous  reactions  may  sometimes 
precede  the  formation  of  the  medullary  sheath.  Furthermore, 
although  Flechsig  has  shown  that  certain  tracts  receive  their 
medullation  at  different  times,  these  investigations  have  not 
thrown  any  light  upon  the  great  area  that  exists  between  the 
point  in  the  cortex  where  so  many  fibres  begin  to  lose  their 
medullary  sheath  and  the  outermost  layer,  a  space  that  is  rich 
in  cellular  elements  and  a  specific  gray  substance  of  great  mor- 
phological as  well  as  functional  importance. 

The  essential  differences  in  the  histological  structure  of  the 
various  cortical  areas  can  not,  except  in  a  very  general  way,  be 
correlated  with  the  functional  differences.  To  suppose,  for 
example,  as  Wernicke  has  done,  that  the  consciousness  of  self, 
of  the  internal  and  of  the  external  world,  are  represented  in 
separate  layers  is  a  purely  hypothetical  conjecture.  The  whole 
subject  of  cortical  localization  needs  revision  in  the  light  of  the 
facts  more  recently  demonstrated  by  the  biologist  and  physiol- 
ogist. The  points  of  discharge  for  efferent  impulses  can  no 
longer  be  considered  as  forming  the  limitations  of  centres,  and 
the  application  of  this  term  itself  is  indefinite. 

The  work  of  Apathy,  Nissl,  and  Bethe  has  clearly  shown 
that  the  relation  between  nerve-cells  and  fibres  is  not  as  simple 
and  clear  as  the  earlier  investigators  would  have  led  us  to 
believe.  As  soon  as  we  are  able  to  establish  definitely  the 
relationship  between  nerve-cells,  nerve-fibres,  and  the  specific 
gray  substance  in  the  cortex,  a  decided  advance  will  have  been 
made  not  only  of  importance  for  the  histologist,  but  one  which 
will  have  an  immediate  bearing  upon  certain  diseases,  particu- 
larly dementia  paralytica  and  certain  other  dementing  processes. 

Even  from  the  little  that  is  known  it  is  justifiable  to  con- 
clude that  the  so-called  specific  gray  substance  is  an  important 
element  in  the  central  nervous  system.  In  animals  where  this 
morphological  element  is  diffusely  arranged,  the  reflex  action 
is  simple  and  the  movements  are  incoordinated ;  but  higher  up 
in  the  scale,  when  the  distribution  of  the  gray  matter  is  limited 
to  certain  areas,  the  movements  become  correspondingly  more 


NATURE    OF    ALIENATION  21 

complex  and  coordinated.  This  is  equivalent  to  saying  that  the 
increase  in  complexity  of  reflexes  and  coordinated  movements 
is  dependent  upon  the  efficiency  of  the  receiving  and  elaborating 
organ.  Recent  investigations  in  morphology  and  physiology- 
have  shown  that  the  ganglion-cell  hypothesis  is,  after  all,  an 
inadequate  attempt  to  account  for  all  the  phenomena  of  reflex 
action.1 

.  As  yet  we  have  only  a  very  imperfect  knowledge  regard- 
ing the  blood  and  lymph-channels  of  the  central  nervous  system, 
and  leaving  out  of  consideration  for  the  moment  the  adventitial 
lymph  spaces,  practically  nothing  is  known  in  regard  to  the 
passage  of  the  blood  through  the  brain  substance.  Recent  in- 
vestigations have  clearly  shown  that  the  so-called  extra-  or 
peri-cellular  lymph-spaces  are  mere  artefacts,  and  this  discovery 
has  thrown  some  light  upon  certain  pathological  processes,  since 
it  is  now  definitely  known  that  the  round  nuclei  which  in  certain 
pathological  changes  are  grouped  about  the  nerve-cell  are  not 
lymphocytes,  as  is  even  believed  by  some  to-day,  but  are 
neuroglia  elements. 

As  regards  the  nerve-cells  themselves,  it  will  be  found  that,, 
valuable  as  the  earlier  contributions  were  in  giving  us  a  more 
accurate  knowledge  of  their  intimate  structure,  later  investiga- 
tions have  as  yet  failed  to  demonstrate  the  relation  of  the 
observed  changes  to  the  general  pathological  processes  or  to  the 
clinical  symptoms.  The  reaction  of  these  structures  is  so  deli- 
cate and  so  many  factors — such  as  pre-agonal  changes — may 
intervene,  that  it  is  almost  impossible  to  deduce  any  general 
conclusions  from  the  countless  number  of  observations  that  have 
been  made  in  regard  to  the  supposed  correlation  of  the  struct- 
ural changes  and  the  clinical  symptoms.  Although  many  in- 
vestigators, in  despair  at  the  slow  progress  that  has  been  made 
in  the  study  of  the  histology  of  the  central  nervous  system,  seem 
to  discourage  further  investigations  along  this  line  and  boldly 
declare  that  the  only  hope  for  a  possible  solution  of  all  this 


1  Bethe,    A. :     Allg.    Anatomie    und    Physiologie    des    Nervensystems. 
Leipzig,  1903. 


22  PSYCHIATRY 

chain  of  problems  lies  in  the  field  of  physics  and  chemistry,  a 
more  conservative  opinion  would  justify  the  belief  that  im- 
portant contributions  still  remain  to  be  made  by  histologist  and 
anatomist.  In  addition  to  those  already  referred  to  there  is 
great  need  of  the  establishment  of  certain  standards  by  which 
an  approximate  and  rapid  estimate  may  be  made  of  the  number 
of  nerve-cells  in  the  different  areas  of  the  cortex  at  different 
periods  of  life  as  well  as  their  diminution  during  disease.  .  The 
studies  of  Henschen  and  others  in  the  pathology  of  idiocy  have 
shown  that  in  these  conditions  the  embryonal  type  of  elements 
persists,  but  whether  there  is  any  considerable  diminution  in 
the  number  of  nerve-cells  is  still  a  matter  for  conjecture. 

What  is  true  of  the  nerve-cell  is  equally  true  of  the  fibre. 
The  studies  in  dementia  paralytica  of  Kaes,  whose  work  is 
referred  to  more  in  detail  later,  has  clearly  shown  how  im- 
portant are  detailed  careful  studies  of  the  relative  number  of 
fibres  in  the  different  cortical  areas  at  different  epochs  of  life 
and  their  diminution  in  various  morbid  conditions. 

If  we  turn  from  the  more  purely  anatomical  and  physio- 
logical questions  to  the  specific  bearing  that  certain  groups  of 
pathological  changes  have  upon  the  symptoms,  it  may  be  said 
that  in  a  few  instances  definite  advances  have  been  made. 
Since  Tuczek  first  accurately  described  the  disappearance  of 
the  tangential  fibres  from  the  cortex  in  general  paresis,  a  large 
body  of  workers  all  over  the  world  have  been  engaged  in  the 
study  of  this  disease,  and  gradually  a  number  of  characteristics 
of  this  pathological  process  have  been  recognized,  so  that  in 
from  80  to  90  per  cent,  of  the  cases  a  positive  diagnosis  of  the 
existence  of  the  paretic  process  can  be  made  directly  from  the 
pathological  findings.  More  recently,  as  will  be  seen  later  on, 
Nissl,  basing  his  observations  upon  the  study  of  individual  cases, 
has  definitely  stated  that  it  is  possible  to  differentiate  the  paretic 
from  the  syphilitic  process.  If  these  observations  are  generally 
confirmed,  it  will  be  possible  to  take  a  decided  step  forward  in 
the  clinical  differentiation  of  the  two  diseases.  On  the  other 
hand,  the  differentiation  of  the  protracted  cases  of  dementia 
paralytica  from  certain  forms  of  the  senile  or  alcoholic  psy- 


NATURE    OF    ALIENATION 


23 


choses  still  awaits  solution.  The  remarkably  careful  and  pains- 
taking work  of  Alzheimer  has  demonstrated  the  possibility  of 
differentiating  anatomically  between  a  number  of  the  arterio- 
sclerotic lesions  and  those  of  general  paresis.  And  again  in 
this  direction  the  paretic  process  has  been  more  definitely  defined 
and  the  boundaries  have  been  more  nearly  established.  Surely 
even  these  advances  are  sufficient  to  justify  the  expectation  that 
within  the  next  decade  this  important  group  of  diseases  will  be 
even  more  accurately  outlined. 

The  problems  of  histopathology  necessarily  bring  us  to  the 
consideration  of  the  manner  in  which  certain  toxic  products  act. 
From  the  evidence  at  our  command  there  can  be  little  doubt  that 
the  series  of  changes,  which  are  noticeable  in  the  nerve-cell  in 
febrile  delirium  and  acute  and  sub-acute  confusional  states,  as 
well  as  in  the  terminal  stages  of  nearly  all  psychoses,  are  the 
result  of  the  action  of  toxins'. 

As  to  the  manner  in  which  these  poisons  act  or  the  source 
from  which  they  are  derived  we  are  still  ignorant,  and,  indeed, 
in  regard  to  the  more  general  subject  of  autointoxication 
practically  nothing  definite  is  known. 

It  is  to  be  hoped  that  gradually  some  light  will  be  thrown 
upon  these  problems,  not  only  by  the  investigations  made  in 
pathology,  but  by  the  results  of  experimental  studies,  especially 
those  in  which  the  pathologist  has  the  assistance  and  coopera- 
tion of  a  well-trained  chemist.  The  field  of  the  experimental 
production  of  anomalies  of  the  cortical  functions  is  one  that  as 
yet  has  hardly  been  entered  upon.  Difficult  as  the  problems  are 
which  are  awaiting  solution,  it  can  not  be  long  before  a  large 
number  of  investigators  will  have  entered  upon  this  field,  in 
which  the  harvest  must  eventually  be  so  rich. 

The  conclusions  reached  by  Cramer  2  deserve  attention,  as 
they  summarize  the  opinions  entertained  by  the  majority  of  in- 
vestigators. This  writer  affirms  that  in  all  forms  of  psychosis 
anatomical   lesions   are   to  be   found,    the  most   severe  being 


2  Pathologische     Anatomie     der     Psychosen,     Handbuch     der    patho- 
logischen  Anatomie  des  Nervensystems.     Berlin,  1904. 


24 


PSYCHIATRY 


demonstrable  in  cases  of  progressive  paralysis  and  in  certain 
forms  of  chronic  alcoholism.  A  condition  similar  to  that  found 
in  cases  of  dementia  paralytica  is  frequently  noticed  in  the 
cortex  of  senile  dements,  but  the  lesions  typical  of  senile  de- 
mentia may  be  differentiated  from  those  of  paresis.  The 
arterio-sclerotic  atrophy  presents,  as  a  rule,  certain  character- 
istic changes.  But  frequently  the  localized  increase  in  the  glia 
is  noted  in  the  senile  psychoses,  in  dementia  paralytica,  and  not 
uncommonly  in  the  so-called  senile  epilepsy.  There  is  no  spe- 
cific change  in  the  glia  noted  in  any  one  psychosis.  The  simple 
psychoses  of  the  senium  not  complicated  by  paralyses  and  not 
connected  with  the  periods  of  great  excitement  or  terminating 
in  dementia  present  the  fewest  alterations.  It  is  still  question- 
able whether  characteristic  glia  changes  are  met  with  in  cata- 
tonic states.  Conditions  of  confusion  with  great  excitement, 
commonly  referred  to  as  acute  delirium,  are,  as  a  rule,  marked 
by  the  appearance  of  a  typical  cortical  encephalitis  which  may 
or  may  not  be  of  an  infectious  character.  Delirium  tremens 
and  other  acute  psychoses  may  be  differentiated  from  general 
paresis  by  the  very  small  number  of  blood-elements  present  in 
the  tissues,  the  absence  of  any  very  marked  diminution  of  the 
fibres,  and  the  failure  to  find  sclerotic  cells.  The  changes  found 
in  the  acute  delirium  are  not  seen  in  any  other  psychoses  except 
in  dementia  paralytica.  Cases  in  which  the  process  has  not 
gone  so  far  as  to  give  rise  to  cell  sclerosis,  disappearance  of 
fibres,  cellular  infiltration,  and  marked  vascular  changes,  with 
great  increase  in  the  glia,  afford  some  hope  for  recovery.  Spe- 
cific cell  changes  for  individual  psychoses  do  not  exist. 

On  the  whole,  then,  it  may  be  said  that  the  hopes  of  those 
who  a  decade  ago  saw  rich  rewards  awaiting  the  investigations 
of  the  neuro-pathologist  have  not  been  justified.  But  is  it  not 
reasonable  to  suppose  that  advances  towards  a  more  compre- 
hensive knowledge  of  the  nature  of  mental  disorders  will 
neither  be  more  rapid  nor  more  delayed  than  one  would  expect 
in  attempting  a  solution  of  problems  equally  difficult  in  other 
branches  of  medicine.  And  while  careful,  painstaking  investi- 
gations conducted  along  all  the  different  lines  which  the  study 


NATURE    OF   ALIENATION  25 

of  this  subject  necessitates  must  evidently  result  in  an  accumu- 
lation of  a  valuable  store  of  facts,  it  would  be  unreasonable  to 
expect  an  immediate  advance  of  psychiatry  from  the  casual 
study  of  isolated  portions  of  the  central  nervous  system.  The 
pathologist  at  the  autopsy  table  should  conduct  his  investiga- 
tions with  the  realization  that  mental  diseases  are  an  expression 
of  disordered  functions  of  the  brain,  but  that  the  causes  for 
these  anomalies  may  be  situated  in  organs  outside  the  central 
nervous  system.  He  must  further  bear  in  mind  the  fact  that 
if  a  pathological  process  once  gives  rise  to  a  disturbance  in  the 
mental  functions,  the  original  trouble  may  become  quiescent 
and  the  aberration  may,  so  to  speak,  become  self-accumulative. 


CHAPTER   III 

THE   SYMPTOMS    OF   ALIENATION 

All  forms  of  alienation  are  to  be  regarded  as  the  results 
of  bodily  disease  in  which  the  disordered  functions  of  the  cere- 
bral cortex  afford  the  most  prominent  and  characteristic  of  the 
symptoms.  Although,  as  has  already  been  said  in  the  opening 
chapter,  the  clinical  study  of  cases  of  insanity  covers  a  very 
wide  range  and  implies  the  application  of  the  methods  employed 
in  clinical  medicine  and  neurology,  only  the  mental  disturbances 
can  be  discussed  within  the  present  compass.  The  anomalies 
in  the  functions  of  the  cerebral  cortex  may  for  convenience' 
sake  be  divided  into  various  categories.  From  a  physiological 
stand-point  the  student  of  mental  processes  has  to  consider  the 
reception,  retention,  and  elaboration  of  sensory  stimuli  and 
finally  the  discharge  of  the  motor  impulse.  It  is  hardly  neces- 
sary to  again  emphasize  the  fact  that  all  the  processes  represent 
merely  various  gradations  and  not  essential  differences  in  qual- 
ity or  character. 

I.    IMPAIRMENT    OF    THE    HIGHER    CORTICAL    FUNCTIONS 

AS     SHOWN     IN     DEFECTS     OF    JUDGMENT    AND 

INTELLECT.      FIXED    OR   INSANE    IDEAS.1 

In  the  present  section  we  shall  not  attempt  to  give  a  de- 
tailed exposition  of  the  anomalies  of  judgment  and  intellect, 
but  rather  to  indicate  the  manner  in  which  they  may  be  studied 
from  a  clinical  stand-point.  Faculties  which  represent  the  most 
complicated  products  of  the  cortical  functions  can  neither  be 
defined  nor  clearly  described.  What  has  been  shown  to  hold 
true  for  the  simpler  mental  phenomena — as  regards  their  de- 

1  Baldwin,  J.  M. :  Mental  Development  in  the  Child  and  the  Race. 
New  York  and  London,  1897.  Tiling:  Ueber  die  Entwicklung  d.  Wahn- 
ideen  u.  Hallucinationen  aus  d.  normal  Geistesleben.  Riga,  1897.  Spiller, 
Gustav:  The  Mind  of  Man.  New  York  and  London,  1902.  Tiling:  Zur 
Paranoiafrage.  Psychiat.  Wchnschr.,  1902,  Bd.  35,  431-442. 
26 


DEFECTS    OF   JUDGMENT  27 

pendence  upon  other  functions — applies  with  even  greater  force 
to  the  discussion  of  these  final  products  of  cerebral  activity. 
In  the  attempt  to  analyze  the  latter  one  must  never  lose  sight 
of  the  fact  that  their  relationship  to  other  functions  is  very 
intimate,  whence  it  follows  that  any  anomaly  of  one  function 
will  to  a  certain  extent  cause  not  an  isolated  but  a  general 
defect.  The  two  terms,  intellection  and  judgment,  for  a  time 
formed  a  part  of  the  stock  in  trade  of  the  older  psychology,  but 
on  account  of  the  speculative  and  fanciful  manner  in  which  the 
discussions  concerning  their  nature  and  origin  were  conducted 
little  real  advance  was  made  towards  a  satisfactory  interpre- 
tation or  analysis  of  them.  As  in  the  case  of  sensation,  mem- 
ory, volition,  or  the  emotions,  so  in  a  study  of  the  intellect 
and  judgment  it  has  been  found  possible  to  split  these  com- 
plexes up  into  a  great  variety  of  simpler  forms  which  merge 
into  each  other  and  concerning  whose  nature  psychologists  and 
alienists  are  gradually  gaining  an  insight.  As  the  character 
of  even  the  simplest  mental  processes  is  at  present  indefinable, 
it  is  not  to  be  expected  that  those  of  greater  complexity  can  be 
differentiated  and  labelled.  There  are  certain  manifestations, 
however,  of  these  functions  that  the  alienist  should  recognize 
and  with  the  genesis  of  which  he  should  show  some  degree  of 
familiarity.  One  of  their  most  striking  features  is  that  they 
depend  upon  the  activity  and  integrity  of  associative  memory, 
so  that  impairment  of  the  latter  is  always  reflected  in  the 
anomalies  of  the  former.  These  particular  mental  processes 
under  discussion  are  of  slow  growth  and  only  attain  their  maxi- 
mum when  the  individual  has  reached  the  prime  of  life.  In- 
tellection and  judgment  necessarily  imply  the  power  to  retain 
in  memory  a  series  of  events  which  may  be  compared  with  the 
more  recent  facts  introduced  into  consciousness.  The  com- 
parison is  made  between  the  earlier  and  the  more  recent  acqui- 
sitions, and  the  individual  then  tries  to  so  adjust  his  conduct  as 
to  justify  inferences  drawn  from  these  comparisons.  If  we 
trace  the  development  of  mental  traits  in  the  infant,  we  find 
that  the  power  to  form  inferences  or  judgments  only  appears  in 
proportion  as  the  faculty  to  retain  and  to  recollect  past  im- 


28  PSYCHIATRY 

pressions  becomes  greater.  The  greater  the  number  of  the  ac- 
quisitions that  are  stored  up  in  memory, — in  other  words,  the 
greater  the  power  of  associative  memory, — the  greater  the  indi- 
vidual capacity  for  intellectual  activity  and  rational  thinking. 
In  the  earliest  years  of  life  sensory  impressions  play  a  far  more 
important  part  than  they  do  later  on,  and  at  first  are  the  domi- 
nating features  in  all  psychic  reactions.  For  example,  when 
the  newborn  infant  takes  the  breast  it  does  so  in  direct  response 
to  sensory  stimulation,  but  gradually  mere  sense  impressions, 
whether  of  intra-  or  extra-organic  origin,  become  replaced  by 
more  complicated  acts  of  associative  memory;  and  these,  as 
the  cerebral  capacity  increases,  may  take  the  place  of  the  primi- 
tive unelaborated  sensory  impressions.  In  the  adult  a  train  of 
associative  thought  which  ends  ultimately  in  the  expression  of 
judgment  may  be  initiated  either  by  a  sensory  impression  or 
by  a  memory-picture.  In  the  least  complex  reactions,  such  as 
those  referred  to  in  the  infant,  the  vividness  of  the  sensory 
impression  is  proportionately  greater  than  the  stimulus  de- 
rived from  memory-pictures.  The  former  is  definite  and  con- 
crete, the  latter  indefinite  and  abstract.  The  study  of  such 
cases  as  that  of  Laura  Bridgman,  in  whom  both  vision  and 
hearing  were  defective,  would  seem  to  justify  the  position  that 
comparatively  few  sensory  impressions  are  sometimes  sufficient 
to  stimulate  complex  memory  and  lead  to  the  formation  of 
equally  complex  concepts  and  judgments.2  An  individual 
may  be  deprived  of  the  various  forms  of  sensory  stimulation 
without  suffering  from  any  serious  interference  with  the  for- 
mation and  retention  of  complex  memory-pictures,  and  may 
also  be  the  possessor  of  an  apparently  undiminished  critical 
faculty.  Some  authors,  however,  who  have  made  the  phe- 
nomena the  subject  of  investigation,  have  failed  to  appreciate 
how  diversified  and  exceedingly  important  in  the  development 
of  the  mental  life  of  the  individual  are  the  so-called  organic 
sensations  apart  from  impressions  derived  from  the  visual  or 
auditory  areas.    The  important  part  that  the  muscle  sense  may 

2  Jerusalem,  W. :   Laura  Bridgman.    Vienna,  Pichler,  1891. 


DEFECTS    OF   JUDGMENT  29 

play  in  psychic  phenomena  has  recently  been  made  the  subject 
of  considerable  investigation,  and  it  would  be  difficult  to  over- 
estimate the  far-reaching  consequences  that  the  organic  sen- 
sations have  upon  the  mental  life  of  the  individual.3  The 
changes  in  the  organic  sensations  and  in  the  muscle  sense  may 
so  seriously  disturb  the  somato-psychic  consciousness  as  to  dis- 
organize connected  thought  and  involve  all  the  more  compli- 
cated cortical  functions. 

In  abnormal  mental  states  where  the  imperious  and  ap- 
parently logical  character  of  the  ideas  would  at  first  lead  the 
observer  to  believe  that  the  primary  disturbance  is  an  intel- 
lectual defect,  a  more  careful  investigation  frequently  shows 
that  the  primary  change  is  an  affective  one.  This  is  also  true 
in  the  conditions  where  the  ideas  are  immobile  and  the  sys- 
tematization  is  marked.  In  children  and  in  primitive  peoples 
the  dominant  features  in  the  mental  processes  are  sensations, 
simple  memory-pictures,  and  affective  states.  It  has  been 
further  observed  that  although  isolated  and  disconnected  in- 
sane ideas  not  infrequently  exist,  the  more  complicated  sys- 
tematized delusions  are  practically  never  met  with.  A  stable 
elaborated  systematized  series  of  insane  ideas  is  an  impossible 
occurrence  in  children,  for,  as  Schultze 4  has  well  said,  the 
paranoiic  must  be  a  finished  builder  in  the  realm  of  thought. 
It  is  always  possible  to  note  great  variations  in  the  affective  life 
of  any  individual  who  subsequently  becomes  the  subject  of 
definite  and  systematized  fixed  ideas.  In  some  instances,  owing 
to  the  change  in  organic  sensation,  the  patient  becomes  nervous, 
restless,  irritable,  and  is  thoroughly  conscious  of  the  fact  that 
a  physical  ailment  has  given  rise  to  some  disturbance  that  in- 
hibits the  completion  of  his  mental  processes.  Gradually  this 
leads  to  mistrust  of  himself  and  then  possibly  of  others.     At 


8  Storch,  E. :  Muskelfunction  und  Bewusstsein.  Eine  Studie  zum 
Mechanismus  der  Wahrnehmungen.  Wiesbaden,  1901.  Kluge:  Ueber  den 
Muskelsinn  und  iiber  seine  Darstellung  bei  Maupassant.  Ztschr.  f.  Psych., 
lx,  S.  414. 

*  Bemerkungen  zur  Paranoiafrage.  Deutsch.  med.  Wchnschr.*  Januar 
14  und  21,  1904,  Nr.  3  und  4. 


30 


PSYCHIATRY 


times  we  meet  with  cases  in  which  a  mild  degree  of  appre- 
hensiveness  or  anxiety  is  constantly  present.  Frequently  it  is 
impossible  to  define  the  exact  mental  state  of  the  patient  except 
to  say  that  there  is  an  indefinite  sense  of  unrest  present  which 
serves  to  fasten  or  tetanize  the  attention.  Then  external  sen- 
sory impressions,  particularly  those  which  on  account  of  the 
surrounding  circumstances  fall  within  the  focus  of  the  atten- 
tion, seem  to  grow  more  vivid  than  normal.  As  a  result  of 
this  condition  changes  occurring  in  the  patient's  own  body,  or 
certain  events  that  transpire  in  the  external  world,  receive  from 
him  more  than  their  share  of  attention.  The  individual's  nor- 
mal sensibility  is  necessarily  disturbed,  and  as  a  result  the  origi- 
nal notion  in  consciousness  is  transformed  and  gives  birth  to  a 
new  idea  which  springs  into  being  so  richly  colored  by  an 
emotional  setting  as  not  to  be  easily  displaced  or  corrected. 
This  process  is  naturally  a  progressive  one.  Clinical  observa- 
tions do  not  tend  to  confirm  the  view  that  these  disturbances 
in  intellection  only  appear  when  there  is  evident  a  general  and 
uniform  impairment  of  all  the  mental  processes,  although  as  the 
systematization  is  developed  such  a  condition  may  present  itself. 
The  intimate  relation  that  exists  between  the  emotional  tone 
and  the  idea  is  shown  in  the  occurrences  of  every-day  life  or  in 
discussions  on  political  or  religious  questions.5  Lecky,  Draper, 
and  others  have  shown  how  important  a  part  these  phenomena 
have  played  in  the  history  of  the  race,  and  every  reader  is  doubt- 
less familiar  with  the  various  outbreaks,  more  or  less  paroxys- 
mal in  character,  of  aberration  which  have  occurred  in  history. 
The  beliefs  in  demoniac  possession,  witchcraft,  and  the  evil 
eye,  so  current  in  the  middle  ages,  and  the  various  manias  of 
modern  times, — for  instance,  spiritualism  or  Christian  Science, 
— which  at  times  have  played  an  important  role  in  the  develop- 
ment of  nations,  are  familiar  examples.  The  limitations  in  the 
field  of  consciousness  and  the  riveting  of  the  attention  upon 
some  one  idea  are  phenomena  that  are  of  frequent  occurrence 
in   women   and   hypersensitive   men,    and,    as    Friedman   has 

B  Friedman,  M. :    Ueber  Wahnideen  im  Volkerleben.    Wiesbaden,  1901. 


DEFECTS    OF   JUDGMENT  3 1 

pointed  out,  are  met  with  even  in  animals ;  for  example,  in  the 
antelope  standing  motionless  and  watching  the  approaching 
caravan  oblivious  of  danger,  or  the  deer  held  spell-bound  by 
the  flash  of  a  lantern. 

Primarily,  all  defects  in  intellect  or  judgment  are  neces- 
sarily associated  with  defects  or  changes  in  consciousness  or 
in  associative  memory.  Wernicke  6  has  affirmed  that  in  the 
cases  of  insanity  which  are  characterized  by  marked  defects  in 
what  is  commonly  called  judgment,  the  content  is  impaired, 
while  the  activity  of  consciousness  is  normal.  Such  a  distinc- 
tion is  misleading,  as  it  necessarily  involves  a  debate  concern- 
ing the  appropriate  use  of  terms  that  are  themselves  more  or 
less  indefinite  and  merely  relative. 

Since  in  all  cases  of  alienation  the  personality  as  such 
suffers,  not  only  should  the  content  of  the  insane  idea  be 
noted,  but  also  the  attempt  should  always  be  made  to  study 
the  synchronous  changes  that  have  occurred  in  the  complex 
of  sensations  upon  which  the  idea  of  personality  depends. 
The  ego  is  never  constant,  varying  as  the  elaboration  of  sen- 
sory impressions  becomes  keener  and  the  activity  of  asso- 
ciative memory  greater.  For  example,  the  belief  of  children 
or  primitive  peoples  in  ghosts  or  spirits  may  readily  be  ex- 
plained on  the  ground  that  the  material  furnished  by  the 
senses  has  not  been  sufficiently  elaborated  and  associative  mem- 
ory has  not  been  actively  stimulated  to  retain  abstract  ideas 
from  which  comparisons  and  rational  judgments  may  be 
formed.  As  the  cerebral  functions  develop  and  the  child  re- 
ceives, retains,  and,  as  need  arises,  develops  these  more  com- 
plex memory-pictures,  it  becomes  able  to  correct  its  false  im- 
pressions as  to  the  existence  of  such  spirits.  But  when  an 
individual  in  the  prime  of  life  complains  that  he  has  been  mal- 
treated and  tormented  by  invisible  spirits,  that  the  room  is 
haunted  by  ghosts  of  departed  friends,  that  he  cannot  write 
a  letter  without  being  assailed  by  unseen  agencies,  the  cause 
of  the  incorrigibility  of  these  ideas  must  be  sought  for  not 

6  Grundriss  der  Psychiatrie,  1900,  S.  101. 


32  PSYCHIATRY 

only  in  the  greater  intensity  of  the  representations,  but  in  the 
more  or  less  complete  dissociation  of  his  entire  individuality. 
What  psychiatry  needs  above  all  things  at  present  is  a  rigid 
study  of  cases,  but  without  attempts  to  form  any  broad  gen- 
eralizations. The  mere  narration  in  a  clinical  history  of  the 
content  of  the  insane  idea  is  an  isolated  fact  of  comparatively 
small  value. 

Recently  considerable  attention  has  been  directed  io  the 
importance  of  the  disturbances  giving  rise  to  anomalies  of 
personality.  From  an  historical  stand-point  it  is  interesting 
to  note  that  as  long  ago  as  1873  the  significance  of  the  changes 
in  organic  sensations  which  form  the  basis  of  this  depersonali- 
zation was  emphasized  by  Krishaber,7  a  laryngologist  and  a 
favorite  student  of  Claude  Bernard.  More  recently  the  work 
of  Janet,  Head,8  and  Pick  9  has  forcibly  redirected  attention 
to  the  great  importance  of  these  alterations  of  organic  sen- 
sibility. Unfortunately,  as  a  rule,  so  few  individuals  afflicted 
with  insane  ideas  come  under  the  observation  of  the  alienist 
until  the  systematization  is  more  or  less  complete  and  im- 
mobile, that  little  satisfactory  progress  has  been  made  in  the 
study  of  the  development  of  these  phenomena.  For  this 
reason  the  large  amount  of  material  which  presents  itself  at 
the  dispensaries  of  any  of  the  large  city  hospitals  is  of  greater 
value  for  study  than  are  the  cases  which  are  admitted  to  our 
hospitals  for  the  insane.  In  practically  every  case  of  aliena- 
tion which  comes  under  observation  early  in  the  development 
of  the  malady  it  will  be  found  that  the  patient  frequently 
complains  of  changes  in  the  organic  sensations  of  such  a 
nature  as  to  interfere  with  the  integrity  of  the  sensations  upon 
which  the  idea  of  individuality  depends.  In  cases  of  manic- 
depressive  insanity,  dementia  prsecox,  and  dementia  paralytica, 
which  have  early  come  under  observation  at  the  dispensary  of 

T  De  la  Nevropathie  cerebro-cardiaque,   1873.     Granier :    Essai  sur  la 
Nevropathie  cerebro-cardiaque  ou  Maladie  de  Krishaber,   1903. 

8  Op.  cit. 

9  Pick,  A. :    Neurol.  Centralbl.,  1903,  Nr.  1 :    Zur  Pathologie  des  Ich- 
Bewusstseins.    Arch.  f.  Psych,  u.  Nervenkrankh.,  1904,  H.  1. 


DEFECTS    OF   JUDGMENT  33 

the  Johns  Hopkins  Hospital,  we  have  been  particularly  struck 
with  the  remarkable  change  occurring  in  the  organic  sensa- 
tions. Of  this  the  following  case  affords  an  excellent 
example : 

A  certain  young  woman  who  at  a  very  early  stage  came  under  observa- 
tion, and  whose  subsequent  history  showed  the  case  to  be  one  of  dementia 

praecox,  frequently  complained  that  she  did  not  "  feel  herself,"  that  "  some- 
thing was  changing,"  and  that  there  was  "  something  the  matter  with  the 
brain."  After  several  visits  to  the  dispensary  her  sister  informed  the  ex- 
amining physician  that  the  patient  had  suddenly  developed  suspicions,  the 
nature  of  which  it  was  at  first  difficult  to  ascertain,  but  which  on  careful 
inquiry  were  found  to  be  of  a  sexual  character.  After  several  unsuccessful 
attempts  had  been  made  to  get  the  patient  to  give  an  account  of  her  symp- 

3 


34 


PSYCHIATRY 


toms,  the  request  was  finally  complied  with  and  the  extracts  from  the 
autamnesis,  which  are  given  here,  afford  an  interesting  revelation  of  the 
genesis  of  these  ideas.  The  patient  lived  on  the  second  floor  of  a  small 
tenement  house,  so  that  when  she  was  lying  in  bed  at  night  she  heard 
sounds  made  by  the  other  boarders  going  up  and  down  the  stairs.  Most 
of  them  were  men,  and  as  the  patient  was  kept  awake  by  the  continuous 
tramping  up  and  down  the  stairs  she  became  very  nervous,  dreaded  going 


to  bed,  and  finally  became  vaguely  suspicious  that  an  attempt  was  being 
made  to  annoy  her.  One  night,  having  experienced  a  feeling  of  suffocation, 
she  suddenly  awoke,  and  immediately  thought  that  somebody  had  thrown 
a  heavy  blanket  over  her.  During  the  remainder  of  the  night  she  was 
more  nervous  than  usual,  so  that  the  next  morning,  on  leaving  her  apart- 
ment and  meeting  a  young  man  who  chanced  to  live  in  the  same  tenement, 
her  suspicions  were  at  once  directed  against  him,  although  later  the  patient 
admitted  that  these  suspicions  were  groundless.     Although  in  describing 


DEFECTS    OF   JUDGMENT  35 

these  ideas  the  patient  did  so  in  a  tone  which  seemed  to  indicate  embarrass- 
ment and  a  disinclination  to  talk  about  such  matters,  on  close  examination 
it  at  once  became  apparent  that  this  emotional  state  was  largely  superficial, 
and  that  in  reality  slight  indifference  and  apathy  with  a  more  or  less  com- 
plete change  in  her  whole  personality  existed.  One  day,  while  being  ques- 
tioned in  the  clinic,  the  patient  suddenly  sprang  from  her  chair  and  asked 
in    an   excited   way   who    was    concealed   behind   the    curtain.     Although 

/Aoc^rL.  -4x^^O  Arc^oL^  CIA.  z  oAj   t^'fci&fc 


4 


<TJp^^v-_, 


,7^  -s-cfA-w'L, 

assured  that  no  one  was  there,  it  was  some  time  before  she  could  be  made 
to  go  and  look  for  herself.  In  a  few  minutes,  however,  she  seemed  to 
realize  that  her  action  was  foolish,  and  said  to  the  examiner  that  she  felt 
some  change,  which  she  could  not  explain,  had  taken  place  in  her  head,  and 
that  in  fact  her  "  whole  person  seemed  to  be  changing."  The  accompanying 
short  account  written  by  the  patient  accentuates  certain  of  the  more  promi- 
nent defects,  such  as  impairment  in  associative  memory  and  the  vague 
suspiciousness. 

An  important  feature  of  these  disturbances  is  the  marked 
perversion  of  "  the  sense  of  self- activity"  which  is  present  in 
all  normal  individuals.  According  to  Bryant,10  self-conscious- 
ness includes  all  those  feelings  of  agency  or  directed  energy 
attending  every  voluntary  act.  Undoubtedly  it  is  a  lack  of 
this  sense  which  is  largely  responsible  for  the  feelings  that 
many  patients  have  that  they  are  mere  automatons  or  are  no 

10  Mind,  1897. 


36  PSYCHIATRY 

longer  the  masters  of  their  own  activity.  Since  the  days  of 
Zeller  and  Griesinger,  the  attention  of  alienists  has  been  di- 
rected to  what  the  earlier  observers  called  psychic  anaesthesias, 
states  intimately  associated  with  this  depersonalization,  in 
which  there  is  a  reduction  or  complete  obliteration  of  many 
of  the  facts  of  consciousness.  Such  conditions  exist  in  melan- 
cholias, giving  color  to  the  fixed  ideas  and  playing  an  im- 
portant role  in  the  delirium  of  negation.  The  importance  of 
these  psychic  anaesthesias  or  paraesthesias  in  the  development 
of  insane  ideas  is  frequently  well  illustrated  in  the  prodromal 
period  of  epileptic  seizures,  a  classic  example  of  which  is  the 
case  of  Crichton  Browne,  referred  to  in  his  Cavendish  lecture 
on  Dreamy  Mental  States.11 

The  patient,  a  youth,  said  he  was  subject  to  frightful  feelings  asso- 
ciated with  a  loss  of  personal  identity,  and  affirmed  that  he  frequently 
seemed  to  lose  his  hold  of  the  universe  and  did  not  know  who  he  was. 
Everything  changed  in  a  twinkling;  both  spatial  and  time  relations  were 
completely  disturbed.  He  was  overwhelmed  by  a  sense  of  terror  and  a 
feeling  that  he  could  never  become  himself  again.  These  dreadful  sensa- 
tions invariably  came  on  when  he  was  alone,  and  sometimes  would  be 
induced  if  he  looked  intently  at  himself  in  a  looking-glass.  His  sister  had 
similar  attacks,  with  a  temporary  loss  of  the  sense  of  personal  identity. 

The  insane  idea  has  been  defined  as  an  abnormal,  incorri- 
gible representation — incorrigible  even  when  the  possessor  of 
the  idea  is  confronted  by  plain,  indubitable  evidence  to  the 
contrary.  As  has  been  already  pointed  out,  the  decision  regard- 
ing the  normal  or  abnormal  character  of  the  idea,  particularly 
if  an  abstract  one,  can  not  be  based  merely  upon  the  content. 
Mercier  has  said  that  "  insanity  does  not  consist  in  delusion, 
but  in  the  disorder  of  the  thinking  process  which  results  in  de- 
lusion." 

The  transition  that  frequently  takes  place  from  the  unreal 
to  the  real  may  be  gradual  or  may  be  accomplished  in  the 
twinkling  of  an  eye.  Although  there  are  many  theories  by 
which  the  attempt  is  made  to  explain  the  series  of  changes 
which  result  in  this  transformation,  none  of  them  is  satisfac- 

uThe  Lancet,  July  6,  13,  1895,  Nos.  3749,  375°. 


INSANE   IDEAS  37 

tory.  The  more  detailed  examinations  made  at  the  bedside 
are  necessary  to  throw  the  desired  light  upon  these  highly 
complex  phenomena.  Much  valuable  information  could  un- 
doubtedly be  obtained  from  a  closer  observation  of  delirious 
patients  in  the  wards  of  general  hospitals.  The  following 
history  is  of  interest  as  it  shows  the  abrupt  change  that  oc- 
curred in  a  case  of  acute  alcoholism. 

The  patient,  a  woman,  was  under  observation  at  the  Sheppard  and 
Enoch  Pratt  Hospital  during  a  typical  attack  of  delirium  tremens,  char- 
acterized by  visual  and  haptic  hallucinations,  associated  with  marked 
apprehensiveness  and  fear.  During  the  height  of  the  attack  the  patient  saw 
a  great  variety  of  fantastic  and  strange  figures  of  human  beings  as  well  as 
of  animals.  She  frequently  complained  of  seeing  enormous  worms  and 
asked  to  have  them  removed  from  her  bed.  At  first  the  vividness  of  the 
representations  in  consciousness  was  very  great.  Gradually,  however,  it 
became  less  and  less,  until  finally  the  patient,  although  occasionally  de- 
claring that  she  still  saw  the  same  dreadful  objects,  did  not  show  any 
degree  of  emotion.  After  the  hallucinations  had  entirely  vanished,  the 
patient  affirmed  that  she  remembered  distinctly  the  instant  when  the  idea 
came  to  her  that  the  figures  she  had  seen  were  not  real.  On  being  closely 
questioned,  she  maintained  that  this  transformation  was  due  in  part  to  the 
decrease  in  the  vividness  of  the  representations.  Associated  with  this  there 
was  also  a  marked  alteration  in  organic  sensations,  and  she  became 
immediately  conscious  of  "  feeling  differently." 

The  change  that  occurs  in  the  chronic  psychoses  takes  place 
much  more  gradually,  and  the  patient  is  frequently  unable  to 
assign  a  definite  time  at  which  a  sufficient  insight  is  gained 
into  his  own  condition  to  enable  him  to  differentiate  the  real 
from  the  unreal. 

Sometimes  the  sense  of  reality  fluctuates,  being  now  more, 
now  less  intense  as  the  affective  state  changes.  For  example, 
in  one  instance,  if  the  attention  was  allowed  to  lapse,  the  indi- 
vidual became  quite  passive  and  the  objective  evidence  of 
suspiciousness  rapidly  faded  away,  only  to  be  revived  with 
intensity  whenever  an  incident  stimulus  served  to  awaken  his 
attention.  At  first  the  individual  became  confused,  next  anx- 
iously expectant,  and  then — sometimes  quickly,  again  more 
slowly — definite  suspicions  crystallized  and  became  so  intense 
as  to  dominate  his  conduct.     The  account  that  follows  was 


38  PSYCHIATRY 

written  by  the  patient  while  in  an  excited  condition.  A  few 
minutes  later,  when  asked  if  his  suspicions  might  not  be  with- 
out foundation  and  merely  notions  that  had  developed  as  the 
result  of  his  nervousness,  he  admitted  that  such  an  explanation 
was  not  improbable. 

"  My  mental  confusion  becomes  great  if  excited  and  this  throws  me 
into  a  condition  I  cannot  describe.  I  went  to  *  *  *  on  a  visit  to  my 
uncle's.  There  I  was  lied  about  in  my  hearing,  then  drugged  and  when  I 
spoke  to  my  uncle  about  what  I  heard,  I  was  told  it  was  a  mistake  and 
could  not  make  anything  of  the  whole  business.  I  had  had  similar  trouble 
before  this  but  not  so  great.  I  wished  to  leave  but  was  prevailed  upon  not 
to  do  so  for  a  while.  Finally  my  uncle  came  back  with  me  himself  when 
I  was  in  a  drugged  condition.  There  was  all  manner  of  talk  of  the  most 
vulgar  description  as  well  as  in  terms  of  the  highest  praise  of  which  I 
could  make  nothing.  I  felt  incapable  of  doing  anything  for  myself  and  my 
uncle  had  sworn  before  God  to  act  the  part  of  a  father  to  me.  I  reached 
home  in  a  dazed  condition,  went  to  bed  and  stayed  there  a  while.  Dr.  C. 
came  to  see  me  and  then  for  the  first  time  I  began  to  believe  that  all  men 
were  liars.  My  sister,  Mrs.  B.,  was  a  rational  person  and  helped  me  out 
for  a  few  days.  The  rest  of  my  family  thought  I  was  crazy  or  at  least 
unbalanced." 

The  evident  reflex  influence  of  the  affective  state  in  en- 
abling the  patient  to  intrench  himself  behind  all  barriers  to 
reason  is  evident  even  in  the  so-called  paranoiic  states  that 
have  persisted  for  years. 

The  transition  from  the  real  to  the  unreal  and  the  corre- 
spondingly slow  regressive  changes  in  the  critical  faculties  are 
frequently  illustrated  in  the  clinic.  The  following  autobio- 
graphical notes,  written  by  a  patient  recovering  from  an  attack 
of  manic-depressive  insanity,  illustrate  this  latter  type  in  the 
evolution  of  the  insane  ideas.  Many  of  the  expressions  used 
by  the  patient  give  at  least  an  inkling  concerning  the  patho- 
genesis of  some  of  the  fixed  and  insane  ideas  to  which  patients 
similarly  afflicted  are  subject.  The  patient  admitted  that  even 
in  the  earlier  years  of  her  life  she  had  shown  slight  eccentrici- 
ties in  character  and  had  had  some  difficulty  in  connected 
thought.  This  is  an  important  point,  as  it  serves  to  emphasize 
a  more  or  less  common  truth  to  the  effect  that  even  in  the  more 
acute  psychoses  the  abnormalities  that  become  marked  during 


INSANE   IDEAS  39 

the  height  of  the  disease  are  in  reality  merely  accentuations  of 
defects  which  have  existed  in  embryo  for  some  time  prior  to 
the  acute  outbreak  of  the  malady.  (The  spelling  and  phrase- 
ology used  by  the  patient  have  not  been  changed.  The  great 
prolixity  and  circumstantiality  are  evident.) 

"  I  will  endeavor  to  give  a  brief  sketch  of  my  whole  life  as  I  think 
certain  things  which  have  happened  in  my  life  no  doubt  had  a  great  deal  to 
do  with  my  present  illness. 

"  When  my  mind  developed  sufficiently  to  enable  me  to  reason  intelli- 
gently, religion  appealed  to  me  strongly.  From  childhood  my  one  desire 
was  to  be  a  true  Christian  and  naturally  the  habit  in  my  childhood  worried 
me  considerably.  I  was  always  very  emotional,  the  most  simple  sermon 
affecting  me.  I  thought  I  had  committed  a  great  sin  and  at  different 
periods  of  my  life  producing  such  depression  that  I  feared  if  I  did  not  tell 
my  mother  I  would  not  go  to  Heaven  when  I  died,  but  I  could  not  tell  her. 
I  did  not  want  her  to  know  she  had  such  a  bad  child.  During  the  summer 
of  my  14th  year  I  remember  one  day  feeling  very  much  depressed  over  my 
childhood,  but  it  passed  away  and  I  was  as  happy  as  any  other  child. 

"  Another  time  very  clearly  I  was  about  seventeen  years  old  and  in  the 
second  year  High  School.  I  was  taken  sick  with  throat  trouble  about  a 
week  previous  to  the  final  examinations,  and  I  was  very  much  worried 
about  losing  so  much  time  which  made  me  very  nervous.  .  .  . 

"  During  this  time  that  same  old  thing  distressed  me  again,  I  got  very 
much  better  of  my  nervousness  and  went  to  the  seashore.  When  I  returned 
I  took  up  school  work  again  and  whether  I  knew  my  lesson  or  not,  I 
became  very  nervous  when  I  rose  to  recite,  so  I  left  school  in  October. 
About  a  year  after  that  I  took  up  stenography  and  made  a  fair  success  of  it 
holding  my  last  position  for  two  years  and  a  half  and  leaving  on  account  of 
financial  difficulties  in  the  firm,  which  happened  in  July,  1903.  Previous  to 
this  in  March,  1903,  my  mother's  mother  died  and  I  spent  a  great  deal  of 
time  at  her  bedside  before  her  death.  My  mother  was  then  taken  seriously 
ill  in  April  with  erysipelas  being  delirious  most  of  the  time  and  taxing 
my  strength  to  the  utmost.  I  slept  very  little  in  the  two  months  my 
mother  was  sick  and  missed  very  little  time  from  the  office.  My  mother 
began  to  improve  in  June.  I  went  to  the  country  the  last  of  July  and 
remained  there  for  six  weeks  thoroughly  enjoying  my  long  vacation,  being 
the  first  one  in  two  years. 

"  When  I  returned  home  I  found  my  mother  extremely  nervous  and 
my  family  thought  best  for  me  to  give  up  stenography  for  a  while  and 
relieve  her  of  the  responsibility  of  housekeeping,  but  my  mother  objected 
to  this  plan  as  she  thought  I  was  not  capable  of  keeping  house,  being  the 
truth  no  doubt,  but  I  was  willing  to  learn.  I  saw  how  everything  was 
being  mismanaged,  the  servant  drinking  most  of  her  time  and  neglecting 
her  work,  and  my  mother  too  weak  physically  to  care  much  yet  insisted  I 
should  not  do  the  managing  I  then  begged  my  mother  to  get  rid  of  this 
woman,  but  being  almost  impossible  to  get  another  one,  we  kept  her,  and 


40  PSYCHIATRY 

she  became  very  much  worse.  I  did  not  like  to  cross  my  mother  or  worry 
my  brothers  with  domestic  affairs  and  had  to  bear  it  alone.  I  saw  clearly 
my  duty  and  was  not  allowed  to  carry  it  into  effect,  although  I  felt  I  must 
change  existing  conditions  in  some  way;  so  I  began  with  the  servant 
thinking  perhaps  I  might  help  her  to  lead  a  better  life,  but  made  very  little 
progress  in  that  direction;  I  then  concluded  /  was  neither  capable  nor 
good  enough  to  change  anything,  or  help  anybody.  This  caused  me  to  be 
very  much  depressed;  pleasure  of  no  kind  interested  me,  reading  did  not 
divert  my  mind  and  at  last  found  it  impossible  to  do  anything  until  I  had 
reformed  this  servant.  I  thought  if  she  became  better  other  things  would 
change.  In  the  evening  I  would  feel  better  than  at  any  other  time,  that  is 
to  say,  I  wasn't  despondent.  I  would  wake  very  early  in  the  morning, 
feeling  the  greatest  remorse  about  what  I  had  done  in  my  childhood  and 
almost  choking  with  emotion,  causing  a  very  bad  effect  upon  my  bowels 
and  I  was  simply  impelled  to  tell  my  mother.  She  gave  me  very  good 
advice  and  told  me  not  to  think  of  things  which  happened  so  long  ago.  I 
felt  a  little  comfortable  but  still  very  much  depressed.  I  still  could  do 
nothing. 

"  I  have  been  a  member  of  church  since  I  was  fourteen  years  old,  and  I 
thought  I  had  become  an  awful  hypocrite  and  must  make  a  public  con- 
fession of  it  ere  I  could  eventually  be  saved,  so  on  the  next  Sunday  morn- 
ing I  broke  down  and  told  my  minister  I  was  a  hypocrite,  but  this  did  not 
relieve  my  mind,  and  early  Monday  morning  when  I  awoke  I  tried  to  pray 
and  could  not  and  went  into  my  mother's  room  and  told  her  I  was  bad 
and  hadn't  surrendered  and  she  could  throw  my  Bible  away,  as  it  meant 
nothing  to  me  any  more.  In  the  afternoon  when  my  father  returned  from 
business  I  went  to  him  and  begged  him  to  send  me  away  from  everybody 
and  I  remember  him  saying  '  Send  my  baby  away  from  me'  with  the  tears 
rolling  down  his  cheeks.  At  the  supper  table  /  acted  so  strangely  that  my 
oldest  brother  immediately  sent  for  the  doctor,  who  pronounced  it  nervous- 
ness, but  I  insisted  it  was  only  devilishness.  He  advised  my  brother  either 
to  send  me  away  somewhere  or  to  his  sanitarium  as  it  was  absolutely 
necessary  to  get  me  away  from  my  mother.  I  consented  to  go  because  I 
did  not  want  to  be  at  home  and  after  being  there  for  about  a  week  I  said 
I  wasn't  sick  or  nervous  and  /  was  committing  an  awful  sin  to  remain 
there,  and  I  was  taken  away.  Now  my  next  great  trouble  was  how  to  con- 
vince my  friends  that  I  was  not  sick.  There  was  a  bazar  going  on  at  the 
church  at  this  time  and  I  had  been  elected  chairman  of  one  of  the  tables, 
but  I  could  not  serve,  although  when  I  returned  from  the  sanitarium  I 
went  to  it  feeling  miserable,  and  when  my  friends  inquired  after  my  health, 
I  answered  them  one  and  all  that  I  hadn't  been  sick.  The  next  Sunday  I 
thought  if  I  would  make  a  public  confession  of  everything  that  I  had  ever 
done  in  my  life  and  how  bad  I  was  then  God  would  give  me  another 
chance,  but  my  pride  would  not  allow  me  to  humble  myself  so.  I  passed 
and  repassed  the  church  several  times  that  morning  and  would  not  go  in, 
when  I  then  realized  /  was  eternally  lost. 

"  I  would  do  nothing  to  please  my  family  and  as  a  last  resort  they  sent 
to  *  *  *  for  my  aunt,  knowing  I  was  devoted  to  both  she  and  her  little 


INSANE   IDEAS 


41 


boy,  and  thinking  possibly  they  might  have  some  effect  upon  me  as  I  had 
declared  I  had  lost  all  love  for  my  family.  I  could  hardly  bear  to  think 
they  had  gone  to  so  much  trouble  for  me.  It  was  simply  impossible  to 
make  them  believe  it  was  devilishness.  My  aunt  after  remaining  in  *  *  * 
for  about  two  days  persuaded  me  to  go  back  with  her  and  being  very 
anxious  to  get  away  from  everybody  I  went.  I  was  still  awfully  depressed 
having  the  vilest  thoughts  and  thinking  of  Hell  all  the  time.  I  thought 
God  could  not  punish  me  too  severely  for  going  to  *  *  *  and  leaving 
my  mother  alone.  I  thought  nothing  was  too  bad  for  me  to  do  now. 
Then  the  horrible  hellish  thought  that  I  would  eventually  become  a  de- 
graded woman  took  possession  of  me  and  I  imagined  all  the  men  on  the 
street  could  read  it  on  my  face.  I  told  my  aunt  every  thought  I  had 
almost,  giving  the  latter  delusion  as  a  reason  for  not  going  out,  and  enter- 
ing into  her  social  life  there.  She  tried  to  convince  me  it  was  my  nerves 
and  I  know  I  must  have  tried  her  patience  to  the  utmost,  especially  as  I 
told  her  /  felt  like  murdering  and  hated  to  see  any  of  her  friends  call  and 
felt  like  choking  them  because  I  was  so  miserable  and  unhappy,  yet  she 
never  complained  and  would  not  write  home  telling  them  how  terrible  I 
was,  but  became  very  cross  that  I  didn't.  I  wrote  one  letter  about  myself 
but  she  refused  to  send  it,  declaring  it  simply  awful. 

"  Then  the  suicidal  mania  developed.  I  thought  rather  than  disgrace 
my  family  and  friends  by  becoming  such  a  person,  I  preferred  death.  Then 
I  thought  it  was  only  a  matter  of  a  short  time  before  I  would  do  some- 
thing very  bad  and  be  sent  to  the  penitentiary,  and  persuaded  my  aunt  to 
take  me  to  the  one  in  *  *  *  and  to  satisfy  my  morbid  curiosity  she  did. 
It  was  simply  living  torture  to  me,  as  I  really  envided  some  of  the  poor 
wretches,  because  I  thought  some  of  them  had  a  chance  to  reform  if  they 
wanted  to,  and  I  remember  my  aunt  laughingly  say  to  me,  '  Well,  have  you 
selected  your  cell?' 

"  When  I  read  it  was  generally  of  murders,  suicides  and  crimes  of  all 
kinds  and  always  come  to  conclusion  I  was  just  as  bad  as  any  criminal  I 
read  about  and  a  great  deal  worse  than  some. 

"  About  this  time  /  did  not  suffer  from  remorse,  and  it  worried  me  as 
I  felt  I  had  lost  all  conscience.  I  became  indifferent  to  everything  not 
caring  whether  I  lived  or  died,  or  was  good  or  bad.  What  was  so  remark- 
able to  me  that  during  this  period  of  indifference  I  could  eat  and  sleep  and 
I  tried  to  convince  my  Aunt  that  if  it  were  my  nerves  instead  of  the  devil,  I 
would  do  neither.  I  went  to  church  only  once  while  in  *  *  *  making 
me  feel  very  badly  and  I  refused  to  go  after  that.  The  Sunday  before 
Christmas  my  uncle  persuaded  me  to  go  to  church  with  him  but  when  we 
got  almost  there  I  would  not  go  in,  giving  as  an  excuse  that  I  felt  nervous. 
When  I  left  him  I  intended  to  jump  into  the  *  *  *  but  every  time  that 
I  seriously  contemplated  suicide,  I  was  prevented  from  carrying  out  my  in- 
tention by  that  awful  thought  I  would  go  to  Hell,  which  was  worse  than 
the  terrible  agony  I  was  then  enduring. 

"  In  the  meantime  my  family  became  very  much  alarmed  as  I  refused 
to  come  home,  or  write  to  them.  Sometimes  I  would  add  a  postscript  to 
aunt's  letters,  telling  how  bad  I  was,  but  never  said  anything  of  the  vile 


42  PSYCHIATRY 

delusion  which  had  developed  in  *  *  *,  so  my  brother  consulted  Dr.  X 
who  communicated  with  Dr.  Z  of  *  *  *  I  was  not  cognizant  of  this 
fact  then,  for  had  I  been  I  would  never  have  seen  him.  He  came  upon  me 
suddenly  one  Sunday  morning,  and  I  was  compelled  to  talk  to  him.  / 
thought  now  all  my  finer  feelings  had  become  benumbed,  while  my  coarser 
ones  predominated  and  were  active  at  all  times,  and  as  I  had  lost  all  the 
pride  I  ever  had,  I  concluded  to  tell  him  anything  that  came  in  my  mind, 
especially  about  that  devilish  delusion,  and  it  would  take  him  but  a  very 
short  time  to  discover  what  a  devil  I  was.  He  argued  with  me  for  two 
hours,  using  his  utmost  efforts  to  impress  upon  me  it  was  my  nerves  and 
not  the  devil.  I  remember  him  saying  to  me,  '  Can't  you  see  that  it  is  just 
possible  the  cells  of  your  brain  might  become  diseased  like  any  other  part 
of  your  body,'  but  having  no  power  of  discernment  whatever  at  that  time, 
how  could  I  comprehend  anything?  He  was  very  kind  and  I  remember  him 
taking  my  hands  in  his  trying  to  comfort  me  like  a  father  would  a  dis- 
tressed child,  telling  me  it  was  a  very  serious  matter  and  he  was  going  to 
write  to  *  *  *  about  me.  I  thought  this  rather  strange  that  he  should 
consult  another  doctor,  as  my  aunt  had  told  me  he  was  considered  a  bright 
man.  Then  the  thought  came  to  me  that  he  would  write  all  I  had  told  him 
and  this  doctor  would  in  turn  tell  my  family  and  to  my  horror  I  found  I 
had  been  caught  in  a  trap,  but  I  thought  God  was  only  beginning  to  punish 
me  for  my  terrible  wickedness  here  on  earth  and  expected  something  dread- 
ful to  happen  at  any  moment,  and  I  was  not  surprised  to  see  my  father  walk 
in  on  New  Year's  day  but  very  much  frightened.  When  he  did  not  censure 
me  for  my  badness,  and  brought  no  bad  news  from  home  I  was  very  much 
relieved.  He  told  me  he  had  come  to  take  me  to  a  very  pretty  place  outside 
of  *  *  *,  and  I  was  more  glad  than  otherwise,  as  I  had  told  my  aunt  to 
put  me  away  somewhere.  I  felt  I  just  could  not  fight  against  them  any 
longer  as  it  was  useless  and  they  believed  nothing  I  told  them,  so  I  acqui- 
esced to  anything  my  father  proposed. 

"  While  on  the  train  though  I  told  him  I  had  changed  my  mind  and 
was  going  home,  as  I  felt  I  could  not  be  any  more  trouble  and  expense  to 
my  family.  Knowing  it  would  be  impossible  to  remain  in  seclusion  at  home 
any  length  of  time  before  my  friends  became  aware  of  it,  and  to  their 
sorrow  what  a  vile  creature  I  had  become  just  by  looking  in  my  face,  I 
really  intended  to  take  my  life  by  asphyxiation  as  soon  as  I  got  there, 
believing  it  was  my  last  opportunity  to  do  so,  but  when  I  arrived  at  *  *  * 
my  sister  and  brother-in-law  before  I  could  hardly  draw  my  breath  put  me 
in  a  hack  and  I  was  brought  here.  Papa  told  me  I  would  remain  here  but 
a  very  short  time  and  I  thought  how  true  that  was,  as  it  would  be  but  a 
very  little  while  before  you  found  what  an  impostor  I  was.  Every  morning 
I  woke  up  I  expected  to  be  the  last  one  here,  as  I  thought  I  would  be  sent 
from  this  place  in  dire  disgrace  and  my  family  would  suffer  for  putting 
me  here.  God  would  not  permit  me  to  deceive  so  many  people,  and  espe- 
cially those  who  were  sick.  Do  you  wonder  that  the  first  few  weeks  I 
hardly  spoke  to  any  one  and  that  I  wanted  to  get  away  but  I  saw  in  a 
very  short  time,  it  was  impossible  and  /  was  miserable.  The  first  month  I 
would  do  nothing  at  all,  then  I  went  to  the  other  extreme  working  nearly 


INSANE    IDEAS  43 

all  day  though  doing  it  mechanically  as  my  fancy  work  did  not  interest 
me  then  in  the  least,  feeling  all  the  time  there  wasn't  any  use  in  living  as 
that  vile  delusion  was  constantly  with  me.  /  then  became  anxious  to  go 
to  the  city  for  one  reason  only  as  I  felt  it  gradually  leaving  me  and  I 
wanted  to  give  myself  a  fair  test,  when  to  my  unbounded  delight  I  found 
that  it  had  and  I  could  look  in  any  man's  face  without  the  slightest  self- 
condemnation.  After  I  returned  the  thought  came  to  me  that  even  if  I 
were  lost,  I  might  be  of  some  use  and  derive  some  pleasure  in  living  for 
others  and  I  did  not  worry  very  much  then  about  being  lost.  On  Saturday 
night,  about  five  days  previous  to  my  physical  collapse,  or  whatever  you  call 
it,  some  one  was  playing  the  piano  and  the  music  impressed  me  to  such  an 
extent  I  thought  what  must  heavenly  music  be  compared  with  this  and  I 
expressed  a  wish  to  Miss  *  *  *  next  morning  I  would  like  to  go  to 
some  church  just  to  hear  the  music  and  shortly  after  that  I  realized  I 
wasn't  lost.     Oh!   what  an  awakening ! 

"  Do  you  wonder  that  I  am  so  happy  and  have  such  a  love  for  nature 
and  everything  beautiful  in  life  after  such  a  horrible  nightmare. 

"  I  have  an  intense  desire  for  knowledge,  and  if  it  is  God's  will  that  I 
get  real  well  and  strong,  I  intend  to  be  something. 

"  Accept  my  deepest  gratitude,  and  may  God  bless  you  and  this 
institution." 

What  follows,  in  marked  contrast  to  the  preceding,  was 
written  several  days  after  the  above  description  had  been  com- 
pleted, and  at  a  time  when  the  patient  was  evidently  quite 
markedly  exhilarated  and  in  a  very  happy  frame  of  mind. 

"  When  I  awoke  yesterday  morning  the  beauty  of  the  day  impressed  me 
immediately  and  like  a  bird  my  first  inclination  was  to  herald  forth  the 
glory  of  it. 

"  After  partaking  of  a  very  light  breakfast,  which  after  assimilation 
did  not  have  a  vtvy  good  effect  upon  my  internal  organs,  being  aware  of 
this  by  the  sudden  feeling  of  pain,  though  disappearing  after  a  while,  I 
interested  myself  in  various  ways  remaining  at  nothing  any  length  of  time. 
I  was  anticipating  with  much  pleasure  the  whole  morning  a  visit  from  my 
father  in  the  afternoon,  knowing  and  feeling  that  he  is  as  delighted  as  I 
at  my  wonderful  awakening.  Every  day  I  have  an  increasing  sympathy  for 
the  patients  here,  which  feeling  I  did  not  experience  when  I  first  came. 

"  I  then  ate  my  dinner  which  made  me  sick  and  feeling  very  tired  I 
rested  a  while  after  it.  Being  relieved  by  the  rest  my  body  received  I 
arose  and  dressed  for  an  afternoon  reception  as  I  expected  a  number  of 
visitors. 

"  Just  before  they  arrived,  however,  having  the  desire  of  pouring  forth 
some  of  the  melody  in  my  soul  which  I  had  felt  all  day  was  there  but  not 
having  the  opportunity  of  expressing,  as  the  only  musical  instrument  attain- 
able was  in  use  the  whole  morning  by  one  Mrs.  *  *  *  who  no  doubt  felt 
the  same  as  I  did,  only  I  thought  took  an  unusually  long  time  in  expressing 


44 


PSYCHIATRY 


it,  and  I  got  very  impatient  but  my  chance  came  at  last  and  taking  ad- 
vantage of  it,  I  enjoyed  and  felt  intensely  the  melody  I  made. 

"  When  my  friends  arrived  we  went  for  a  walk,  and  though  going  but 
a  very  short  distance  I  became  very  tired.  Hereafter,  I  am  afraid  I  must 
limit  to  some  extent  the  number  of  friends  whom  I  desire  to  have  on  these 
days  set  apart  for  receiving  as  too  many  excite  me  for  I  have  neither  the 
physical  strength  nor  the  mental  ability  to  entertain  more  than  two  or  three 
at  one  time.  I  remember  we  were  over  on  the  '  casino'  porch  and  my 
sister  referred  several  times  to  something  I  had  promised  to  do  for  her 
several  weeks  ago  and  being  in  rather  an  exalted  state  at  the  present  time, 
material  things  not  appealing  to  me  in  the  least,  I  became  very  cross  and 
nervous  when  she  persisted  in  it,  but  the  thought  came  to  me  at  once  how 
ridiculous  and  weak  of  me  not  to  have  more  control  of  myself.  I  enjoyed 
my  evening  meal  and  after  resting  a  while  after  it,  several  of  us  strolled 
over  to  the  casino.  The  twilight  both  impressed  and  affected  me  to  such 
an  extent  that  I  felt  a  perfect  peace  and  good-will  to  all  man-kind  that  I 
think  one  only  feels  when  they  have  a  deep  love  for  God  in  their  heart 
and  a  reverence  for  His  handiwork. 

"  When  we  returned,  we  played  cards,  being  taught  by  the  ladies  for 
the  first  time  the  game  of  euchre  and  grasping  their  explanation  of  it 
readily,  which  would  have  been  impossible  weeks  ago,  and  in  fact  my 
reasoning  power  is  better  than  ever  in  my  life." 

The  direct  dependence  of  insane  ideas  upon  anomalies  in 
organic  sensations  is  frequently  shown  in  protracted  cases  of 
manic-depressive  insanity,  and  finds  its  best  exemplification 
in  instances  where  there  is  a  "  crossing  of  symptoms,"  such  as 
psychomotor  excitement  with  the  feeling  of  depression  and 
limitations  in  connected  thought.12  In  such  instances  it  be- 
comes clearly  apparent  that  the  mere  increase  in  intensity  of 
an  intestinal  sensation  is  not  sufficient  to  account  for  the  devel- 
opment of  an  insane  idea,  but  its  presence  indicates  the  latency 
of  other  factors,  such  as  inhibition  and  mental  depression. 
If  the  mere  accentuation  in  the  value  of  the  sensation  were  the 
sole  causative  factor,  insane  ideas  would  be  common  in  those 
neuroses  in  which  there  is  a  marked  hyperesthesia  in  the  realm 
of  the  organic  sensibility. 

The  clinical  characteristics  of  the  majority  of  insane  or 
fixed  ideas  are  easily  recognizable,  although  the  basis  upon 


12  Pfersdorff,  K. :    Ueber  intestinale  Wahnideen  in  manisch-depressiven 
Irresein.     Centralbl.  f.  Nervenheilk.  u.  Psych.,  Marz,  1904. 


INSANE    IDEAS 


45 


which  they  are  classified  is  purely  an  empirical  one,  adopted 
with  the  sole  idea  of  facilitating-  description.  Some  observers 
think  that  they  are  capable  of  being  divided  into  two  groups, 
to  one  of  which  belong  all  those  ideas  which  are  of  a  more  or 
less  pleasant  character  and  to  the  other  those  of  an  unpleasant 
nature.  The  former,  including  those  in  which  the  ideas  are 
associated  with  states  of  exhilaration,  an  increased  sense  of 
well-being  and  pleasurable  sensations,  are  much  less  often  of 
forensic  importance  than  are  the  latter,  where  suspicions,  ideas 
of  persecution,  and  so  on,  are  apt  to  bring  the  patient  into 
conflict  with  his  environment.  Another  important  point  from 
the  clinical  stand-point,  and  which  has  reference  to  their  gene- 
sis, is  that  some  of  the  ideas  are  apparently  primary  in  char- 
acter, while  others  are  secondary,  developing  as  a  result  of 
hallucinations  or  preexisting  ideas. 

The  following  history,  accompanied  by  the  patient's  own 
interpretation  of  his  mental  disorder,  is  a  graphic  illustration 
of  the  development  of  certain  states  of  suspiciousness  and  the 
subsequent  well-defined  ideas  of  persecution.  For  various 
reasons  the  history  has  been  considerably  abbreviated. 

For  several  years  the  patient  had  exhibited  symptoms  of  nervousness 
and  emotional  instability.  This  was  said  to  be  due  to  a  disappointment  he 
had  experienced  in  not  receiving  a  position.  An  indefinite  history  of  a 
somewhat  similar  attack  was  obtained,  occurring  six  months  prior  to  the 
present  illness.  The  causes  of  the  present  illness,  as  already  stated,  were 
said  to  be  disappointment  and  a  tendency  to  brood  over  supposed  troubles. 
Later  it  had  been  noted  that  the  patient  was  suspicious  of  people  with  whom 
he  came  into  contact,  and  attributed,  very  unjustly,  certain  motives  to  them, 
such  as  a  desire  to  annoy  and  persecute  him.  One  day  a  stranger  entered 
the  building  where  the  patient  was  acting  as  watchman  and  accosted  him 
in  a  friendly  manner.  The  patient  at  once  became  excited,  and  when  the 
stranger  in  a  familiar  way  placed  his  hand  upon  his  shoulder  the  patient 
thought  it  was  for  an  improper  purpose  and  immediately  assaulted  his 
interrogator.  The  patient  was  at  once  taken  into  custody,  and  after  exami- 
nation was  transferred  to  the  Sheppard  and  Enoch  Pratt  Hospital,  where 
he  was  admitted  on  September  i,  1903.  He  was  found  to  be  in  a  very 
emotional  state,  claimed  that  he  had  been  the  subject  of  conspiracy,  but  that 
he  would  unearth  the  scheme  even  if  violence  were  necessary.  On  Septem- 
ber 6  the  patient  was  quiet  and  jovial,  greeting  the  physician  and  attendants 
cordially  and  affirming  that  the  hospital  was  a  "  grand  place  for  rest."  On 
the   following   day  he  again  became  excited,   declared  that  he  had  been 


46  PSYCHIATRY 

persecuted,  and  wished  to  get  out  a  writ  of  habeas  corpus,  as  he  had  a 
"  strong  case  against  the  hospital  for  illegal  detention."  He  was  very  in- 
sistent, declaring  that  everything  had  been  done  to  annoy  him  and  to  "  tear 
his  clothes  to  pieces,"  but  that  his  indomitable  will-power  had  held  him 
together.  Furthermore,  he  declared  that  he  had  not  slept  two  hours  since 
he  had  been  in  the  institution,  and  that  lights  were  flashed  into  his  room 
and  kept  him  awake.  He  said  that  when  he  took  a  bath  the  attendants 
squirted  muddy  water  into  the  bath  as  soon  as  he  got  in.  He  refused  to  take 
medicine  after  the  first  dose,  declaring  that  half  an  hour  after  it  had 
been  taken  he  felt  everything  giving  way  inside  of  him.  He  became  greatly 
excited  while  talking  and  shook  his  fist  in  the  attendant's  face.  He  admitted 
that  he  was  never  suspicious  before  he  came  to  the  hospital,  but  on  this 
occasion  he  was  suspicious  of  every  movement  and  act  and  would  believe 
nothing  that  was  told  him.  The  emotional  states  varied,  the  patient  some- 
times complying  with  requests,  at  other  times  refusing  absolutely  to  do  as 
he  was  bid.  On  October  10  he  narrated  to  the  examining  physician  the 
circumstances  relating  to  the  trouble  which  resulted  in  his  being  brought 
to  the  hospital.  When  asked  who  the  examining  physician  was  he  at  once 
declared  that  he  was  the  book-keeper,  but  would  not  give  any  reason  for 
maintaining  this  position.  When  pressed  for  an  answer  he  was  quiet  for  a 
time,  apparently  absorbed  in  his  own  thoughts,  and  then  replied,  "  Gentle- 
men, you  are  interfering  with  my  work,  I  must  be  going,"  and  immediately 
started  to  walk  up  and  down  the  corridor.  The  following  week,  when 
again  visited  by  the  same  physician,  the  patient  at  once  addressed  him  as 
"  Mr.  X."  "  That  is  who  you  are ;  you  are  the  book-keeper  for  the 
hospital."  He  firmly  maintained  that  the  doctor  had  an  object  in  deceiving 
him,  but  would  give  no  reason  for  his  belief.  A  few  days  after  this  he 
affirmed  that  the  questions  which  had  been  asked  him  by  the  physician  the 
preceding  week  had  caused  him  to  have  "  pyrotechnics,"  owing  to  which  he 
had  been  obliged  to  remain  in  bed  all  day. 

Note  of  December  4.  The  patient  has  improved  remarkably  in  the  last 
few  weeks ;  admits  that  all  of  his  former  delusions  were  foolish  and  laughs 
at  them. 

From  this  date  until  his  discharge  (January  13)  recovery  was  uninter- 
rupted. The  following  account  was  given  by  the  patient  himself,  and  em- 
phasizes some  of  the  important  points  connected  with  the  genesis  of  his 
delusions.     (The  patient  had  only  had  a  common-school  education.) 

"  When  I  entered  the  Hospital  I  was  for  the  first  night  and  day  placed 
in  the  second  ward.  I  slept  in  the  Dormitory  on  the  evening  of  the  next 
day  I  was  transferred  to  the  first  ward  and  on  the  following  morning  I  was 
transferred  to  the  fourth  ward.  I  spent  about  five  days  there  when  I  was 
placed  in  third  ward  for  acting  in  a  disorderly  manner  and  accusing  Mr. 
X  of  having  evil  designs  on  me.  This  was  imaginary  on  my  part  as  he  was 
simply  trying  to  induce  me  to  eat  more;  on  the  second  day  of  my  stay  on 
the  third  ward  it  suddenly  struck  me  that  I  should  do  something  to  employ 
my  mind  noticing  the  marks  of  many  kinds  on  the  walls  of  the  room  I 
occupied,  I  commenced  to  count  them  when  I  reached  a  hundred  I  would 
repeat.     I  found  this  helped  me  to  a  great  extent  or  I  at  least  thought  so. 


IX S AXE    IDEAS  47 

I  was  transferred  to  second  ward  and  after  spending  a  few  days  in  a 
despondent  mood  the  same  idea  of  counting  up  to  one  hundred  and  repeat- 
ing occurred  to  me  again ;  this  I  followed  and  continued  for  some  time — 
then  I  conceived  the  idea  that  by  employing  my  mind  and  exercising  ray 
body  I  could  hasten  my  cure  at  this  time  I  began  to  suspect  all  of  the 
attendants  and  some  of  the  patients  of  trying  to  retard  my  recovery.  This 
only  made  me  more  determined  than  ever  to  get  well  so  I  continued  my 
exercises  a  short  time  after  this  I  saw  Dr.  A  for  the  first  time  he  was 
examining  the  eyes  of  Mr.  H.  To  me  at  that  time  he  appeared  the  specialist 
a  short  time  after  this  he  again  visited  the  ward,  in  the  meantime  I  had 
heard  the  name  of  *  *  *  When  I  saw  Dr.  A  the  second  time  and  was 
questioned  by  him  it  suddenly  entered  my  mind  that  he  was  Mr.  F.  I  told 
him  so  and  that  he  was  a  book-keeper — not  a  doctor — the  Saturday  follow- 
ing I  again  saw  Dr.  A  but  refused  to  believe  he  was  such  a  person — I  had 
taken  a  dislike  to  Mr.  X  from  the  first  time  I  saw  him  so  when  on  the 
night  of  October  18th  I  saw  him  turn  off  the  electric  light  in  front  of 
Dormitory  I  thought  this  meant  my  return  to  Dormitory  to  be  followed  by 
a  transfer  to  ward  3d — this  I  determined  to  prevent  by  improving  my  con- 
dition by  constant  exercise  so  I  started  to  walk  the  corridor  up  and  down 
at  nine  p.m.  I  retired  to  rest  and  slept  soundly  until  six  o'clock  a.m.  when 
I  awoke  I  realized  after  some  thought  that  I  had  been  suffering  with 
hallucinations  from  that  morning  I  continued  to  improve  both  in  mind  and 
body  and  at  the  present  time  I  feel  as  well  as  if  not  better  than  I  have  felt 
in  three  years — I  want  to  say  the  feeling  of  resentment  entertained  by  me 
towards  Mr.  X  has  been  changed  to  admiration  and  respect." 

Some  of  the  delusions  in  rare  instances  seem  completely 
to  annihilate  the  idea  of  personality.  The  past  is  obliterated, 
and  the  individual  no  longer  retains  any  knowledge  of  his 
former  self  and  thus  exhibits  a  more  or  less  definite  dual  per- 
sonality. Such  complete  changes  are  noticed  in  the  wandering 
mania  of  hysteria  or  epilepsy  and  in  certain  other  psychoses. 
Generally,  however,  the  insane  idea  seems  to  involve  only  a 
part  of  the  individuality* :  an  arm  or  a  leg  becomes  glass  ; 
the  contents  of  the  skull  have  been  changed ;  voices  are  located 
in  the  abdominal  cavity.  Again,  in  other  instances,  the  relation 
of  the  individual  to  his  environment  becomes  the  subject  of 
mental  aberration,  which  may  assume  a  pleasant  or  an  un- 
pleasant character.  When  the  former  occurs,  the  patient's 
idea  of  well-being,  of  his  personal  worthiness,  of  his  compe- 
tence, are  all  intensified,  and  may  become  so  greatly  exagger- 
ated that  he  becomes  Hercules,  Xapoleon,  or  Rothschild,  and 
even  assumes  supernatural  powers    ( megalomania). 


48  PSYCHIATRY 

In  the  antithetical  states  the  change  is  of  an  entirely  differ- 
ent character.  The  sense  of  well-being  is  then  impaired  and 
the  consciousness  of  organic  processes  becomes  painfully  in- 
tensified (micromania).  The  material  wants  are  ill  supplied. 
Such  patients  declare  they  are  impoverished,  utterly  worthless, 
they  have  lost  all  their  physical  and  mental  vigor,  have  com- 
mitted unpardonable  sins,  and  the  like. 

Again,  the  insane  ideas  indicate  an  inimical  relation  of 
the  individual's  environment  to  himself.  Thus  are  formed 
various  suspicions,  in  some  instances  vague  and  general,  in 
others  definite,  well-defined,  systematized,  and  imperious  in 
character.  In  the  milder  cases  there  is  simply  general  distrust ; 
but  in  the  latter  there  are  definite  delusions  of  persecution  which 
drive  the  individual  to  the  commission  of  overt  acts.  The 
more  specific  characteristics  of  these  systematized  ideas  are 
described  in  the  consideration  of  the  various  types  of  aliena- 
tion. 

II.  ANOMALIES    IN    THE    INTENSITY    AND    DIRECTION    OF 

THE   MENTAL   PROCESSES   AS    SHOWN   IN   DISORDERS 

OF    THE    ATTENTION. 

The  phenomena  of  the  attention  are  to  be  regarded  not 
only  as  the  weather-vanes  that  indicate  the  direction  of  the 
mental  processes,  but  also  as  gauges  by  which  the  intensity 
and  volume  of  the  latter  are  measured.  In  different  indi- 
viduals there  is  a  wide  latitude  within  which  fluctuations  may 
occur,  so  that  even  normally  there  exist  personal  idiosyncrasies 
and  modifications  in  the  stream  of  attention,  these  personal 
variations  being  referable  to  distinctive  dissimilarities  in  the 
functional  capacities  of  the  nervous  system.  Nor  is  it  un- 
natural that  inheritance  and  acquisition  should  bring  about 
a  difference  in  the  manner  in  which  two  given  organisms  will 
respond  to  similar  stimuli.  In  the  one  instance  certain  needs 
and  trends  arise  that  do  not  exist  in  the  other.  One  person 
attends  with  ease  to  a  certain  subject,  while  a  second  fails 
utterly  in  the  attempt.  During  the  waking  states  the  brain 
is  constantly  active  and  never  ceases  to  operate;    its  energy 


DISORDERS    OF   ATTENTION  49 

flows  first  in  one,  then  in  another  direction.  Incident  stimuli 
of  intra-  as  well  as  extra-organic  origin  are  received  and  in 
some  instances  retained.  In  one  case  the  incident  stimulus  is 
like  the  spent  arrow  striking  the  mark,  but  unable  to  penetrate 
it.  In  another,  the  shaft  sinks  deeply  beneath  the  surface  and 
a  permanent  impression  remains.  This  is  the  beginning  of  a 
complex  train  of  thought  that  may  be  rich  in  possible  con- 
nections. Normally,  if  the  energy  is  flowing  strongly  in  one 
direction,  a  new  stimulus  of  only  ordinary  strength  will  fail 
to  divert  the  flow  from  a  given  channel.  In  cases  of  alienation, 
however,  the  flow  is  often  so  superficial  that  the  slightest  re- 
sistance interposed  is  sufficient  to  change  the  course  of  the 
stream.  The  never-ceasing,  uninterrupted  activity  of  the  cere- 
bral functions  is  as  constant  as  the  cardiac  action  or  the  move- 
ments of  respiration.  If  the  heart's  action  becomes  irregular 
or  the  breathing  labored,  there  is  no  general  rule  by  which  the 
intensity  of  these  phenomena  can  be  measured  and  no  single 
term  by  which  each  special  occurrence  can  be  described.  Nor 
is  it  unnatural  that  the  same  should  be  true  for  the  attention. 
Physiology  has  shown  that  the  forces,  the  combination  of  which 
is  designated  as  attention,  in  reality  represent  the  coefficient 
that  indicates  the  functional  capacity  of  the  brain.  When  the 
activities  of  the  higher  brain  centres  are  in  abeyance,  as  in 
sleep  or  states  of  unconsciousness,  there  is  no  such  thing  as 
attention.  Stimuli  impinge  upon  the  cerebral  cortex  but  no 
reaction  follows.  Impressions  must  be  retained,  elaborated, 
and  brought  into  connection  with  other  psychic  unities,  so 
that  before  they  can  determine  the  flow  of  attention  the  stimuli 
must  be  of  sufficient  strength  and  the  activity  of  the  brain 
capable  of  responding.  In  health  all  the  conditions  are  favor- 
able. The  attention  flows  along  certain  channels  which  are 
primarily  determined  by  inherent  qualities  as  well  as  by  those 
acquired  through  education.  In  various  states  the  attention 
or  flow  of  energy  is  dissipated;  and  even  if  the  stimuli  are 
of  such  strength  that  under  normal  conditions  they  would 
awaken  a  response,  they  now  fail  to  bring  about  any  syn- 
thesis or  connected  train  of  thought.     This  lowering  of  the 

4 


5o 


PSYCHIATRY 


power  of  elaboration  and  of  the  working  up  of  stimuli  may 
be  temporary,  as  in  states  of  drowsiness  or  fatigue,  or  may 
be  permanent,  as,  for  example,  in  various  forms  of  dementia. 

Not  only  is  attention  necessary  for  thought,  but  it  is  a 
factor  in  all  volitional  acts.  Thought  without  attention  is 
inconceivable.  The  amount  and  intensity  of  the  flow  of  en- 
ergy gives  character  to  the  thought.  When  there  is  a  shallow 
or  more  or  less  diffuse  discharge  of  energy  our  impressions 
are  faint;  they  scarcely  rise  above  the  so-called  threshold 
and  are  easily  forgotten.  These  faint  and  imperfectly  elabo- 
rated impressions  are  frequently  referred  to  as  sub-conscious. 
There  is  nothing  startling  or  inexplicable  about  them.  It  is 
the  faintness  of  the  impression  which  makes  them  elusive,  and 
the  indefinable  becomes  the  source  of  a  certain  degree  of  mys- 
tery. Such  expressions  as  unconscious  mind  or  sub-conscious 
thought  are  meaningless — they  are  simply  a  play  upon  words. 
Attention  is  associated  with  every  mental  process.  A  sensa- 
tion implies  the  existence  of  a  certain  degree  of  attention. 
Some  of  the  phenomena  included  under  this  term  may  be  de- 
scribed, but  cannot  be  categorically  defined.  If  the  intra- 
organic stimuli  were  abolished,  there  would  be  no  attention, 
and  without  this  drift  or  set  in  the  current  sensory  stimulation 
would  create  no  appreciable  effect. 

Although  our  minds  are  constantly  flooded  with  a  stream 
of  sensory  impressions,  all  do  not  attain  equal  vividness  nor 
are  they  retained  in  memory.  At  one  time  this,  at  another 
time  that,  object  occupies  the  field  of  attention.  This  selection 
is  not  volitional,  but  is  determined  for  us  by  a  variety  of 
causes  that  depend  upon  the  physical  properties  of  the  brain. 
The  power  to  receive  and  retain  new  ideas  may  be  termed  the 
recording  faculty  (the  Merkfahigkeit  of  Wernicke).  The 
vigility  of  the  attention  is  a  term  used  by  some  clinicians  to 
indicate  the  fact  that  the  direction  of  the  stream  of  energy 
is  dirigible.  The  tenacity  refers  to  the  length  of  time  during 
which  the  current  sets  in  a  given  direction.  Decrease  in  vigil- 
ity (Hypovigility)  is  noted  in  various  conditions.  It  is  a 
common  symptom  of  fatigue,  as  a  consequence  of  which  stim- 


DISTURBANCES    OF    SENSATION  51 

uli  stronger  than  those  normally  needed  are  required  to  direct 
and  augment  the  flow.  The  influence  of  various  drugs,  par- 
ticularly opium  and  the  bromides,  may  also  be  productive  of 
similar  results.  The  tenacity  or  persistence  of  the  attention 
is  profoundly  affected  in  various  forms  of  alienation.  Not 
only  is  this  true  in  well-marked  psychoses,  but  frequently  also 
in  various  functional  neuroses — hysteria  and  neurasthenia. 
Not  uncommonly  vigility  and  tenacity  are  both  affected,  giving 
rise  to  a  condition  called  aprosexia.  In  this  condition  stimuli 
produce  little  or  no  effect  upon  the  cerebral  functions ;  response 
is  reduced  to  a  minimum,  and  if  under  abnormally  intensified 
stimuli  a  reaction  follows,  it  is  isolated  and  unproductive. 

In  certain  excited  conditions  the  slightest  stimulus  pro- 
duces an  immediate  reaction.  Waves  spread  in  all  directions 
as  soon  as  the  surface  is  broken  by  a  ripple.  This  hyper- 
vigility  is  common  in  neurasthenia,  alcoholism,  mania,  and 
various  other  conditions.  As  a  rule,  the  tenacity  is  decreased 
rather  than  increased.  Each  new  impression  serves  to  deflect 
the  attention.  This  phenomenon  has  been  designated  hyper- 
prosexia.  The  patients  in  whom  this  symptom  is  marked  take 
everything  in  at  a  glance,  pass  with  lightning-like  rapidity 
from  one  object  to  another,  but  are  strangely  deficient  in  the 
power  to  carefully  examine  the  details  of  any  one  of  them. 

In  some  conditions,  particularly  in  cases  of  hallucination, 
the  attention  seems  to  be  firmly  riveted  upon  the  object  occupy- 
ing the  field.  The  tenacity  is  increased  while  the  vigility  is 
essentially  lowered. 

III.  DISTURBANCES    OF   SENSATION,   INCLUDING   HALLUCI- 
NATIONS. 

The  interest  of  the  alienist  is  practically  centred  in  three 
phases  of  the  physiology  of  sensation;  in  the  first  place,  he 
studies  the  facts  connected  with  the  reception  and  transmis- 
sion of  stimuli,  either  intra-  or  extra-organic  in  nature,  from 
their  point  of  origin  to  the  central  termination  of  the  sensory 
tract ;  secondly,  he  is  directly  concerned  with  the  investigation 
of  the  nature  of  the  transformation  of  these  impulses  and  their 


52  PSYCHIATRY    • 

elaboration  and  relation  to  the  various  psychical  activities; 
and,  finally,  he  endeavors  to  correlate  the  relationship  that 
exists  between  the  associative  activities  of  the  brain  and  their 
objective  expression  in  reflex  or  volitional  acts.  This  three- 
fold division  of  function  is  empirical.  The  clinician  should 
recognize  that  there  is  a  difference  of  degree  but  not  of  kind 
in  all  three,  but  while  admitting  the  necessity  of  employing 
terms  to  designate  the  phenomena  of  sensation,  he  should 
never  lose  sight  of  the  fact  that  the  expressions  employed  are 
merely  relative.  Clinically,  the  main  interest  is  directed  to 
the  fact  that  stimuli  under  certain  conditions  give  rise  to  a 
series  of  psychic  events  which  are  called  sensations.  It  is 
impossible  to  even  enumerate  the  different  steps  that  occur  in 
the  transformation  and  elaboration  of  simple  sensations  into 
the  most  complex  of  psychic  phenomena.  The  gradations 
hitherto  established  are  purely  artificial.  For  all  that  is  known 
to  the  contrary,  the  only  form  of  cerebral  function  of  which 
we  are  cognizant  is  that  of  associative  memory.13  The  fact 
cannot  be  emphasized  too  frequently  that  in  describing  sen- 
sory phenomena  terms  are  used  merely  to  designate  a  con- 
nection or  series  of  relationships  between  the  psychic  elements 
that  is  never  constant,  but  is  always  in  a  state  of  flux.  When- 
ever possible  it  is  advisable  to  substitute  a  terminology  not 
limited  in  its  application  and  significance  by  special  use.  In 
recording  clinical  observations  a  phraseology  chosen  from  the 
vocabulary  of  the  physiologists  is  preferable  to  that  in  vogue 
among  the  psychologists. 

In  a  study  of  sensation  three  paths  of  investigation  may 
be  followed :  ( i )  we  may  content  ourselves  with  analyzing 
and  recording  the  mental  phenomena;  (2)  we  may  make  the 
physical  processes  which  give  rise  to  the  sensation  the  subject 
of  special  inquiry;  or  (3)  we  may  employ  a  combination  of 
these  two  methods  and  thus  obtain,  as  experience  has  demon- 
strated, the  most  satisfactory  results  by  correlating  as  far  as 


13  Loeb,  Jacques :    The  Physiology  of  the  Brain.     The  Science  Series, 
G.  P.  Putnam's  Sons,  1900. 


DISTURBANCES    OF    SENSATION  53 

possible  the  psychic  and  the  physical  processes.  Every  sen- 
sation is  made  up  of  a  certain  number  of  elements.  These 
elements  are  physical  processes — for  example,  sound  or  light 
waves.  Not  only  are  our  sensations  formed  by  the  union  of 
elements,  but  more  complicated  psychic  phenomena,  generally 
referred  to  as  volition,  ideas,  and  emotions,  may  be  similarly 
analyzed.  Between  the  physical  processes  or  stimulus,  on  the 
one  hand,  and  the  most  complicated  volitional  acts,  on  the 
other,  there  is  an  unbroken  chain.  A  few  of  the  links  are 
recognized;  many  are  not,  but  the  inference  that  the  contin- 
uity of  this  chain  is  unbroken  is  a  safe  and  warrantable  de- 
duction. Sensations  are  the  first  link  in  the  chain  of  mental 
phenomena.  It  is,  therefore,  natural  that  they  should  first 
be  made  the  subject  of  investigation  before  considering  more 
complex  mental  processes.  Sensations  are  the  most  elemen- 
tary form  of  all  our  psychic  activities  and  are  the  functional 
elements  of  consciousness.  The  recognition  of  the  fact  that 
sensations  cannot  be  isolated  from  other  mental  processes  and 
studied  by  themselves  is  a  matter  of  practical  as  well  as  of 
theoretical  interest.  "  They  cannot  arise  in  consciousness  with- 
out the  simultaneous  occurrence  of  thought,  attention,  memory, 
and  pleasure  or  pain"  (Mercier).  They  form  an  integral  part 
of  all  the  complicated  associative  cerebral  activities  and  must 
be  studied  in  their  relation  to  other  phenomena — the  attention, 
feelings,  emotions,  etc.  Not  only  is  this  true,  but  the  con- 
current variance  in  the  physical  states  must  also  be  carefully 
investigated. 

Under  normal  conditions,  when  a  stimulus  of  sufficient 
strength,  originating  either  within  or  without  the  body,  is 
received  and  transmitted  by  the  conducting  nerves  to  the  cere- 
bral cortex,  a  sense  perception  is  the  result.  Gustave  Spiller  14 
has  justly  emphasized  the  necessity  of  keeping  clearly  before 
our  minds  the  variety  as  well  as  the  complexity  of  the  trans- 
formations that  may  occur  in  the  impulse,  and  of  which  we 


14  Spiller,   Gustave :    Mind  of  Man.     London,   Swan,   Sonnenschein  & 
Co.,  Limited :    New  York,  Macmillan  &  Co.,  1902,  p.  134. 


54  PSYCHIATRY 

have  only  the  vaguest  inkling.  The  nervous  system  should 
be  compared  to  a  vast  factory,  and  not  to  a  mere  telegraphic 
network. 

With  but  few  exceptions,  physiologists  until  recently  have 
accepted  the  hypothesis  first  enunciated  by  Weber,  but  gener- 
ally associated  with  the  name  of  Johannes  Miiller,  to  the  effect 
that  different  stimuli  when  acting  upon  the  same  sense  organ 
give  rise  to  specific  sensations.  Helmholtz  was  the  first  to 
suggest  certain  modifications  of  this  doctrine  of  the  specific 
energy  of  the  nerve-centres  in  order  to  explain  tone  and  light 
perceptions.  This  investigator  held  that  certain  modifications 
took  place  in  the  impulse  during  its  transmission  through  the 
receiving  and  transmitting  organs.  He  even  went  so  far  as 
to  affirm  that  in  certain  cases  the  sensory  cellular  elements 
in  the  cerebral  cortex  might  change  the  character  of  the  im- 
pulse. Other  workers  have  formulated  more  definite  objec- 
tions to  this  doctrine.  Wundt,15  basing  his  belief  upon  the 
facts  known  regarding  the  development  of  the  sensory  areas, 
affirms  that  as  these  complex  centres  develop  from  simple  and 
similar  structures,  they  do  so  only  in  response  to  external 
stimuli.  From  this  the  deduction  follows  that  as  the  quality 
of  the  sensation  is  thus  determined  secondarily  by  the  results 
of  external  stimuli,  the  hypothesis  that  predicates  belief  in 
the  inherent  specific  energy  of  the  nerve-centres  is  incom- 
patible with  the  facts.  The  argument  is  carried  still  further, 
and  attention  is  directed  to  the  point  that  great  diversity  in 
the  character  of  sense  perceptions  can  not  be  explained  merely 
by  a  corresponding  difference  in  the  individual  sensory  ele- 
ments. The  objection  of  clinical  importance,  to  the  effect 
that  those  born  blind  or  deaf,  even  if  the  sensory  nerves  con- 
necting the  end  organ  and  the  centres  are  intact,  are  devoid 
of  appreciation  of  both  auditory  and  visual  perceptions,  is  a 
serious  drawback  to  the  acceptance  of  the  theory. 

The  intensity  and  quality  of  our  sense  perceptions  depend 

15  Wundt :     Grundriss    der    Psychologic      Fiinfte    Auflage.      Leipzig, 
1902. 


DISTURBANCES    OF    SENSATION  55 

upon  several  factors:  (1)  the  stimulus;  (2)  the  receptive  and 
transmitting  capacity  of  the  nerve  tract  which  joins  the  periph- 
eral sensory  organ  with  its  central  area;  and  (3)  what  Hux- 
ley has  called  the  sensifacient  capacity  of  the  cerebral  cortex. 

Every  sensation  is  commonly  said  to  have  certain  charac- 
teristics :  quality,  intensity,  space  attributes,  duration,  and, 
finally,  a  tone  feeling  of  either  pleasure  or  pain.  These  attri- 
butes, singly  or  in  combination,  may  be  affected  by  disturb- 
ances occurring  within  the  body  during  the  course  of  an  alien- 
ation. In  order  that  a  stimulus  may  be  appreciated,  it  must 
have  a  certain  strength.  This  is  generally  expressed  by  saying 
that  the  sensation  rises  above  the  threshold  of  consciousness. 
In  physiological  terms  this  is  equivalent  to  affirming  that  the 
strength  of  the  stimulus  has  been  sufficient  to  produce  in  the 
normal  functioning  nerve-centres  a  responsive  action.  In 
other  words,  a  definite  connection  between  the  different  proc- 
esses, called  memory,  feeling,  and  sensation,  has  been  estab- 
lished. Should  the  responsive  action  of  the  nerve-centres  be 
impaired  by  disease  or  the  conduction  of  the  impulse  rendered 
difficult,  the  connections  normally  established  do  not  exist  and 
the  sensation  never  rises  above  the  threshold  of  consciousness. 
The  physiological  processes  which  are  a  part  of  the  sensation  do 
not  cease  at  the  instant  that  the  threshold  of  consciousness  is 
passed,  but  have  a  tendency  to  persist — a  phenomenon  of  prac- 
tical importance.16 

Every  alienist  is  familiar  with  the  fact  that  in  certain 
cases,  particularly  in  dementia  or  in  profound  mental  depres- 
sion, a  considerable  time  may  elapse  from  the  instant  that  the 
stimulus  impinges  upon  the  peripheral  receiving  organ  until 
there  is  objective  evidence  of  its  appearance  in  consciousness. 
It  is  not  improbable  that  chemical  changes  occurring  in  the 
tissues  interpose  greater  resistance  to  the  transmission  of  the 
stimulus.  A  delay  may  also  occur  in  the  birth,  elaboration, 
and  discharge  of  the  afferent  impulse. 


16  Miiller,  G.  E.,  and  A.  Pilzecker :    Experim.  Beitrage  zur  Lehre  vom 
Gedachtniss.     Ztschr.  f.  Psych.,  etc.,  1900,  Erganzungsband  I. 


56  PSYCHIATRY 

In  the  congenital  defect  psychoses,  such  as  idiocy,  imbe- 
cility, etc.,  the  sensifacient  activity  of  the  cortex  is  unquestion- 
ably impaired  by  its  incomplete  development  and  the  persist- 
ence in  some  instances  of  embryonal  types  of  the  neural  ele- 
ments. In  other  cases  the  imperception  is  the  result  of  regres- 
sive cortical  changes.  It  is  not  at  all  improbable  in  still  other 
cases  that  the  diminished  functional  activity  is  the  result  of 
an  increased  resistance  to  the  conduction  of  impulses  situated 
in  the  nerves  themselves.  Lesions  not  infrequently  occur  dur- 
ing the  course  of  alienation  that  give  rise  to  disturbances  in 
the  sensory  areas  supplied  by  the  peripheral  nerves — in  Kor- 
sakow's  psychosis,  etc.  The  disorders  of  this  nature  are  fully 
treated  of  in  the  text-books  on  neurology. 

Disturbances  in  sense  perception  occur  in  various  forms 
of  alienation  that  are  not  referable  to  lesions  in  the  conducting 
tracts,  but  are  psychically  conditioned.  These  are  called  psycho- 
anaesthesias,  psycho-hypersesthesias,  and  psycho-algias.17  The 
cutaneous  sensibility  is,  as  a  rule,  intact.  Impairment  of  con- 
sciousness and  the  deflection  of  the  patient's  attention  in  a 
large  measure  give  rise  to  these  states,  which  interfere  with 
the  functioning  of  the  sense  organs  and  of  the  general  organic 
sensibility.  Their  occurrence  is  recognized  in  many  instances 
by  careful  examination  and  the  exclusion  of  evidence  point- 
ing to  the  existence  of  peripheral  lesions.  In  connection  with 
the  clinical  investigations  of  the  anomalies  of  sense  percep- 
tion there  are  a  few  facts  of  great  importance  that  should  be 
kept  in  mind.  The  stimulus  and  the  resulting  sense  perception 
under  normal  conditions  bear  to  each  other  certain  propor- 
tional relations.  When  this  equilibration  is  seriously  disturbed 
we  have  what  is  called  an  abnormal  perception.  The  normal 
relationship  between  the  stimulus  and  the  resulting  perception 
may  be  disturbed  in  several  ways. 

Further  than  this,  as  has  already  been  pointed  out,  the 

17  Bechterew :    Ueber  Storungen  im  Gebiete  der  Sinnesperception  bei 
Geisteskranken.     Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  xiii,  Heft  6,  1903, 

S.  590. 


HALLUCINATIONS  57 

state  of  consciousness  at  the  time  of  the  incidence  of  the 
stimulus  is  an  important  factor  in  every  sense  perception.  In 
sleep,  in  stuporous  states,  in  dementia,  the  visible  reaction 
only  follows  a  stimulus  whose  intensity  is  far  above  the  nor- 
mal. In  all  conditions  in  which  the  voluntary  attention  is 
disturbed  the  same  lack  of  correspondence  between  the  inten- 
sity of  the  stimulus  and  the  perception  becomes  apparent.  The 
fact  that  a  strong  stimulus  may  produce  no  reaction  if  a  pa- 
tient's attention  is  diverted  is  a  matter  of  common  observation. 
On  the  other  hand,  in  certain  emotional  states,  such  as  excite- 
ment or  fear,  there  is  often  a  great  diminution  or,  it  may  be, 
complete  absence  of  any  apparent  reaction.  This  may  be  due, 
as  we  have  seen,  to  peripheral  disturbances,  or  it  may  be  cen- 
trally conditioned  and  depend  solely  upon  the  deflection  of 
the  attention.  Disturbances  of  sensation  which  are  of  especial 
interest  to  the  alienist  are  those  commonly  described  as  hallu- 
cinations or  illusions.  As  has  been  said,  all  sensory  impres- 
sions when  once  stamped  upon  the  neural  elements  as  the  direct 
result  of  peripheral  stimulation  may  be  re-collected. 

Sensory  memory,  that  process  which  occurs  in  the  central 
nervous  system  as  the  direct  result  of  a  peripheral  stimulation 
and  which  conditions  the  return  of  sensory  phenomena,  may 
exceptionally  occur  without  peripheral  stimulation,  and  then 
becomes  the  source  of  fantasms  or  hallucinations.  Every  one 
at  times  is  subject  to  hallucinations  or  illusions.  The  cor- 
rigibility  or  incorrigibility  of  these  phenomena  is  the  test 
by  which  we  judge  as  to  whether  they  are  or  are  not  com- 
patible with  perfect  sanity.  The  patient  may  suffer  for  years 
from  auditory  hallucinations.  He  recognizes,  however,  the 
fallacious  character  of  the  perception,  and  his  conduct  is  not 
in  any  way  determined  by  it.  No  one  would  suppose  for 
an  instant  that  an  individual  was  insane  simply  because  he 
was  subject  to  hallucinations,  but  as  soon  as  he  becomes  doubt- 
ful whether  the  false  sense  perception  should  not  be  permitted 
to  influence  his  conduct  he  may  be  said  to  be  on  the  border- 
line between  sanity  and  insanity,  and  when  he  becomes  con- 
vinced that  the  vision  or  the  voice,  as  the  case  may  be,  possesses 


58  PSYCHIATRY 

categorical  attributes,  then,  unquestionably,  alienation  in  the 
legal  or  lay  sense  is  present.  The  processes  of  sense  percep- 
tion, as  has  already  been  stated,  may  be  both  quantitatively 
as  well  as  qualitatively  disturbed.  The  alienist  is  only  con- 
cerned with  the  consideration  of  those  qualitative  changes 
where  the  power  to  discriminate  between  what  is  true  and  what 
is  false  in  perception  is  inhibited. 

In  1832  Esquirol  in  his  classical  work  18  divided  abnor- 
mal sense  perception  into  two  classes  :  ( 1 )  Illusions — sense 
perceptions  that  are  objective,  false  interpretations  of  external 
objects;  and  (2)  hallucinations,  those  that  are  purely  sub- 
jective. In  the  former  case  there  is  an  external  stimulus, 
which  in  a  measure  is  the  exciting  cause  of  the  phenomenon, 
but  the  interpretation  of  the  sensation  as  it  appears  in  conscious- 
ness is  a  false  one.  Accompanying  the  peripheral  stimulus 
there  is  an  error  in  judgment  associated  with  every  illusion. 
Recently,  Ziehen  has  suggested  the  following  theory  as  a  possi- 
ble explanation  for  the  occurrence  of  hallucinations.  He  sup- 
poses that  the  stimulus  takes  its  origin  in  the  cortical  cells  and 
is  discharged  in  the  opposite  direction  to  the  course  taken  by 
the  normal  stimulus.  The  psychical  processes  referred  to  by 
Kahlbaum  as  re-perception  are  explainable  on  the  basis  of  this 
theory. 

In  hallucinations  the  subjective  representation  may  be 
so  exaggerated  as  to  be  indistinguishable  from  a  true  percep- 
tion. The  presentation,  or  act  of  associative  memory,  that 
is  normally  a  constituent  of  every  perception,  is  reduced  to  a 
minimum.  It  is  questionable,  however,  whether  this  factor 
is  ever  entirely  wanting,  as  it  is  almost  impossible  in  examin- 
ing patients  with  hallucinations  to  preclude  the  possibility  of 
its  existence.  From  a  practical  stand-point,  however,  the  pre- 
sentation or  external  stimulus  in  many  cases  may  be  said  to 
be  deficient.  The  flies  crawling  over  the  bedclothes  of  the 
patient  suffering  from  delirium  tremens  are  thought  to  be 
angels  or  devils,  and  we  are  therefore  justified  in  regarding 

1S  Sur  les  illusions  des  sens  chez  les  alienes. 


HALLUCINATIONS  59 

these  sensory  phenomena  as  mere  illusions.  The  fantastic 
figures  seen  by  the  alcoholic  at  night  or  the  voices  heard  by 
him  when  in  a  quiet  room  are  commonly  said  to  be  hallucina- 
tions, but  it  is  absolutely  impossible  to  tell  in  each  instance 
whether  an  external  stimulus  does  or  does  not  enter  into  this 
phenomenon.  The  sensory  plainness  of  hallucinations  is  one 
of  their  most  striking  characteristics.  Elementary  hallucina- 
tions are  the  simplest  form  of  these  phenomena,  viz.,  simple 
sounds,  akoasmata,  or  flashes  of  light,  photomata.  Between 
these  simple  varieties  and  the  extremes  there  are  all  degrees 
of  difference. 

Baillarger  distinguished  two  kinds  of  hallucinations — 
psycho-sensorial  and  psychic.  The  first  are  the  result  of  a 
combined  action  of  the  imagination  and  of  the  organs  of  sense. 
They  are  determined  by  an  involuntary  exercise  of  memory 
and  imagination  to  which  a  sensory  stimulus  is  added.  Psychic 
hallucinations  are  said  to  be  the  result  of  the  exercise  of  mem- 
ory and  imagination  without  the  interposition  of  a  sensory 
stimulus.  The  psychic  hallucinations  of  sound  are  the  most 
frequent.  Patients  describe  them  as  "  indistinct  or  spiritual 
voices,"  "  the  communications  between  mind  and  mind," 
"  thoughts  coming  as  inspiration,"  "  voices  without  sound," 
etc.  These  phenomena  are  referred  to  by  some  as  pseudo- 
hallucinations,  by  others  as  apperceptive  hallucinations.  To 
distinguish  sharply  between  the  psychic  and  psycho-sensorial 
hallucinations  is  impracticable.  The  possibility  always  exists 
of  the  inability  of  the  observer  to  exclude  the  presence  of  a 
sensory  stimulus.  Lugaro19  has  directed  attention  to  what 
he  believes  to  be  the  distinctive  characteristics  of  pseudo- 
hallucinations.  These  phenomena  occur,  as  a  rule,  in  chronic 
cases.  The  imagination  plays  an  important  part  in  their  eti- 
ology. They  lack  the  distinctive  characteristics,  vividness,  and 
objectiveness  of  sensory  phenomena.    They  are  associated  with 


13  Lugaro,  E. :  Sulle  pseudo-allucinazioni  (allucinazioni  psichiche  di 
Baillarger).  Riv.  d.  Patologia  nervosa  e  mentale,  1903,  vol.  viii,  fasc.  I 
and  II. 


6o  PSYCHIATRY 

disturbances  of  the  psychic  processes  connected  with  hearing 
and  seeing  or  with  the  muscular  sense.  A  common  charac- 
teristic is  their  coherence  and  the  apparent  antagonism  to  other 
facts  of  consciousness.  Synchronous  disturbances  in  the  per- 
sonality are  frequently  noted.  As  a  rule,  they  may  be  easily 
distinguished  from  true  hallucinations  as  well  as  from  the  so- 
called  psycho-motor  disturbances  of  perception. 

Many  attempts  have  been  made  to  explain  the  pathogene- 
sis of  these  so-called  psychic  hallucinations,  but  as  yet  none 
of  the  reasons  given  are  entirely  satisfactory.  The  same  is 
also  true  for  that  peculiar  condition  in  which  patients  believe 
that  their  thoughts  become  audible  to  those  about  them  (Ge- 
dankenlautwerden).  Individuals  afflicted  in  this  way  often 
refuse  to  answer  questions,  declaring  that  their  thoughts  are 
already  known  to  the  physician.  The  symptom  may  develop 
in  normal  individuals,  particularly  during  states  of  fatigue  or 
after  the  ingestion  of  certain  drugs  (e.g.,  caffein,  alcohol, 
hyoscin).  The  defects  in  judgment  and  imagination  common 
in  mental  disorders  give  rise  on  the  part  of  the  patient  to  false 
interpretations  of  these  phenomena.  Sometimes  the  incidence 
of  either  auditory  or  visual  stimuli  seems  by  suggestion  to  be 
an  important  exciting  element  in  their  production. 

In  many  cases  in  addition  to  audible  thinking  there  is  an 
acoustic  hyperesthesia.  The  patients  complain  of  a  whistling 
or  rumbling  in  their  ears,  or  there  may  be  definite  audi- 
tory hallucinations.  One  or  several  voices  are  said  to  repeat 
the  thoughts.  When  the  individual  has  command  of  more 
than  one  language  the  thoughts  are  repeated  in  the  same  lan- 
guage in  which  they  were  first  apprehended.20  There  are 
those  who  maintain  that  audible  thinking  is  due  entirely  to 
disturbances  in  the  acoustic  areas,  while  others  affirm  that 
the  phenomenon  is  caused  by  abnormal  stimuli  affecting  the 
centres  associated  with  the  muscular  movements  concerned  in 


20  Probst,  M. :  Ueber  das  Gedankenlautwerden  und  iiber  Halluzina- 
tionen  ohne  Wahnideen.  Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  xiii,Ergan- 
zungsheft,  S.  401. 


HALLUCINATIONS  6l 

speech.  Clinically  there  are  two  forms — one  in  which  the 
content  of  the  hallucination  is  strange,  and  the  other  in  which 
it  is  more  or  less  closely  connected  with  the  individual's  train 
of  thought.  Between  "  audible  thinking"  and  the  so-called 
primary  hallucinations  there  are  various  gradations;  in  some 
instances  the  two  coexist.  The  ideational  hallucinations,  those 
taking  the  form  of  actual  sounds,  as  well  as  the  primary  forms, 
are  so  closely  associated  that  it  is  frequently  difficult  to  differ- 
entiate them.  In  many  cases  audible  thinking  is  associated 
with  the  occurrence  of  insane  ideas  or  delusions.  Exceptions 
to  this  rule  are,  however,  not  infrequent.  There  may  or  may 
not  be  disturbances  of  hearing. 

The  projection  of  the  audible  thoughts  varies — sometimes 
they  are  close  at  hand;  at  other  times  they  seem  to  be  at  a 
distance.  At  times  speech  diminishes,  although  occasionally 
it  increases  in  intensity  and  vividness. 

In  cases  in  which  the  functional  activity  of  any  sense  area 
has  been  completely  destroyed  by  congenital  structural  defects, 
as  in  those  born  blind  or  deaf,  hallucinations  of  the  corre- 
sponding sense  never  occur.  The  reports  to  the  contrary  are 
not  reliable.  The  case  is  different  in  acquired  blindness  or 
deafness.  Uthoff21  reports  a  case  in  which  the  patient  was 
blind  in  both  eyes  and  yet  suffered  from  "  very  dazzling  and 
troublesome  flashes  of  light."  In  this  individual  the  peripheral 
visual  apparatus  was  absent,  but  there  was  undoubtedly  some 
abnormal  stimulus  affecting  the  rest  of  the  visual  tract  and 
giving  rise  to  these  annoying  hallucinations. 

Jastrow  22  has  shown  that  if  the  sight  is  lost  before  the 
"  critical  age,"  from  five  to  seven,  the  individual  does  not  pos- 
sess any  power  of  visualizing  and  never  even  experiences 
dream  visions.  These  interesting  studies  all  tend  to  strengthen 
the  belief  that  the  power  of  a  cortical  centre  to  function  de- 
pends upon  the  education  it  has  received,  and  that  if  this 
education  has  been  sufficient,  the  power  of  function  may  per- 


Monatsschr.  £.  Psych,  u.  Neurol.,  Bd.  v,  S.  372. 
:  Jastrow:    Fact  and  Fable  in  Psychology.     Houghton,  Mifflin  &  Co. 


62  PSYCHIATRY 

sist  for  a  very  considerable  period  even  without  sense  stimu- 
lation. This  view  has  been  substantiated  by  the  results  of 
clinical  observations.  Probst  23  reports  the  case  of  an  adult 
in  whom  both  the  visual  centres  were  destroyed,  and  in  spite 
of  this  the  patient  not  only  was  able  to  conceive  of  forms  and 
colors,  to  picture  to  himself  the  house  in  which  he  lived  and 
his  surroundings,  as  well  as  to  describe  accurately  the  appear- 
ance of  his  friends,  but  also  suffered  from  visual  hallucina- 
tions. The  case  is  of  great  importance,  showing  that  the 
visual  centres  themselves  are  not  necessary  for  the  production 
of  visual  memory. 

Those  who  are  congenitally  deaf  have  no  appreciation 
of  sound  and  never  are  afflicted  with  auditory  hallucinations. 
The  cases  reported  in  which  deaf-mutes  are  said  to  have  had 
auditory  hallucinations  can  probably  be  explained,  as  some 
have  suggested,  by  the  heightened  perception  of  the  arterial 
pulsation.  Under  perfectly  normal  conditions  hallucinations 
do  not  follow  peripheral  irritation  alone.  Bonhoeffer,  in  his 
very  interesting  study  of  the  psychical  disturbances  in  alco- 
holics, has  given  the  chief  reasons  which  militate  against  the 
acceptance  of  the  peripheral  theory  as  presented  by  Liepmann 
and  others.  The  singing  in  the  ears  which  is  often  so  dis- 
tressing to  anaemic  patients  does  not  by  any  means  depend 
solely  upon  the  throbbing  of  the  vessels.  Every  clinician  is 
familiar  with  the  subjective  sensations  of  light,  sound,  and 
pain  from  which  the  neurasthenic  often  suffers,  and  these  are 
doubtless  dependent  upon  the  hyperexcitability  of  the  central 
nerve-centres,  a  condition  which  may  result,  as  has  frequently 
been  suggested,  but  for  which  no  proof  has  yet  been  presented, 
from  an  autointoxication.  Similar  anomalies  of  function  are 
common  in  many  diseases :  nephritis,  tuberculosis,  epilepsy, 
as  well  as  in  poisoning  due  to  alcohol,  lead,  mercury,  etc.  The 
so-called  elementary  hallucinations  of  light,  simple  flashes  of 
light  or  color,  may  indicate  lesions  in  the  cuneus,  but  also 
occur  in  various  forms  of  alienation. 

23  Probst :   Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  ix,  H.  I,  S.  5. 


HALLUCINATIONS  63 

Elementary  auditory  hallucinations  (akoasmata,  acousto- 
mata),  simple  sounds,  may  be  the  results  of  lesions  localized 
within  the  temporal  lobe,  but  the  visual  forms  may  be  among 
the  prominent  symptoms  of  mental  disease. 

Anomalous  taste  sensations  (parageusias)  are  not  infre- 
quent. Sometimes  these  sensations  may  be  definitely  charac- 
terized as  sweet,  sour,  etc.  The  hypodermic  injection  of  mor- 
phine has  been  known  to  be  followed  by  a  bitter  taste  which 
persisted  for  some  time.  The  occurrence  of  similar  disturb- 
ances has  been  noted  in  santonin  poisoning.  Diabetics  at 
times  are  said  to  have  a  sweet  taste  in  their  mouths.  Many 
other  examples  of  this  character  might  be  given,  but  these 
phenomena  are  not  to  be  regarded  as  hallucinations.  Frankl- 
Hochwarth  24  has  shown  that  these  sensations  are  frequently 
indefinite,  and  are  referred  to  as  unpleasant,  nauseating,  etc. 
Fallacious  sense  perceptions  of  taste  have  been  frequently  ob- 
served in  cases  of  facial  paralysis,  middle-ear  catarrh,  and  in 
tabes,  as  well  as  in  epilepsy,  neurasthenia,  and  hysteria.  The 
lesions  of  the  olfactory  centres  in  relation  to  the  occurrence 
of  hallucinations  of  smell  have  also  been  carefully  studied.25 
Frigerie's  case  is  of  great  interest  in  this  connection,  as  there 
was  an  atrophy  of  the  left  pes  hippocampi  major. 

Fallacious  perceptions  of  smell  may  follow  (a)  toxic  in- 
fections, (b)  structural  changes  due  to  compression  of  the 
olfactory  tract,  tabetic  and  senile  changes,  or  may  be  noted 
(c)  in  neuroses,  epilepsy,  hysteria,  and  neurasthenia. 

Hallucinations  may  be  either  unilateral  or  bilateral  and 
may  occur  as  such  in  connection  with  any  of  the  senses. 
Seguin  26  was  the  first  observer  to  call  attention  to  the  subject 
of  unilateral  hallucinations.  The  auditory  are  more  common 
than  any  other  forms.  This  may  be  due  to  the  asymmetrical 
development  of  the  auditory  centre.  The  unilateral  visual  hal- 
lucinations are  nearly  always  associated  with  definite  lesions  in 

24  Die  nervose  Erkrank.  des  Geschmacks  u.  Geruchs,  Wien,  1897. 

25  Jackson  and  Stewart,  Brain,  vol.  xxii,  page  534.     Siebert,  Monats- 
schr.  f.  Psych,   u.  Neurol.,  Bd.  vi,  S.  81. 

28  Journal  of  Nervous  and  Mental  Disease,  August,  1881. 


64  PSYCHIATRY 

either  the  peripheral  or  central  part  of  the  optic  tract.  The  in- 
ference is  not  justifiable  that  unilateral  lesions  in  a  sensory  tract 
always  give  rise  to  unilateral  hallucinations.  There  have  been 
a  number  of  cases  reported  in  which  a  unilateral  lesion  of  the 
sensory  tract  was  followed  by  a  bilateral  hallucination.  Cases 
of  antagonistic  auditory  hallucinations  occur.  In  one  instance 
recorded  by  Magnan  the  patient  heard  voices  in  one  ear  which 
gave  rise  to  the  idea  of  persecution,  and,  later,  in  the  other  ear, 
voices  which  became  the  basis  of  a  pronounced  megalomania. 
Uthoff  27  has  reported  cases  of  great  interest  which  emphasize 
the  causal  relation  that  may  exist  in  those  who  are  subject  to 
visual  hallucinations  between  the  structural  changes  and  the 
functional  disturbances.  The  evidence  so  far  accumulated  all 
tends  to  emphasize  the  necessity  of  making  an  effort  to  deter- 
mine the  existence  of  defects  in  the  peripheral  apparatus,  and 
in  cases  of  scotoma  to  see  whether,  as  is  so  frequently  the 
case,  the  hallucinations  correspond  to  the  restricted  field  of 
vision.  Great  care  should  also  be  taken  in  examining  patients 
with  visual  hallucinations  to  determine,  if  possible,  whether 
the  visual  field  is  hemianopic.  One  interesting  case  has  been 
reported  in  which  a  patient  who  was  hemianopic  saw  in  the 
blind  field  only  the  halves  of  curious  fantastic  figures.  Uni- 
lateral visual  hallucinations  are  more  commonly  associated 
with  peripheral  disease  of  the  eye  than  with  lesions  in  the 
retro-bulbar  part  of  the  optic  tract.  Too  great  emphasis 
should  not  be  attributed  to  the  importance  of  peripheral  ocular 
disease  as  the  immediate  cause  of  visual  hallucinations.  It 
has  frequently  been  stated  that  the  visual  hallucinations  of 
the  alcoholic  are  to  a  great  extent  conditioned  by  the  variations 
in  the  intraocular  blood-pressure.  The  disappearance  of  hal- 
lucinations on  closing  the  eyes,  or  their  movement  synchronous 
with  that  of  the  eye-balls,  has  been  observed  in  cases  of  periph- 
eral as  well  as  central  disturbance.  The  apparent  movement 
of    the    animals'    faces,    figures,    etc.,    so    common    in    many 


27  Beitrage  zu  den  Gesichtstauschungen  bei  Erkrankungen  des  Sehor- 
ganes.    Monatsschr.  f.  Psycfr.  u.  Neurol.,  Bd.  v,  S.  241. 


HALLUCINATIONS  65 

psychical  disorders,  may  be  due  to  disturbances  in  the  nuclear 
region  of  the  ocular  muscles.  In  one  case  that  came  under 
observation  the  patient  had  external  strabismus  of  the  right 
eye,  and  the  visual  hallucinations  seemed  to  correspond  with 
his  field  of  vision.  The  patient  saw  a  single  group  of  angels 
when  he  closed  one  eye,  but  two  distinct  groups  when  both 
eyes  were  open.  The  visions,  according  to  the  patient's  state- 
ment, were  "  projected  upon  the  wall  of  the  room,"  but  they 
did  not  seem  to  grow  smaller  or  larger,  as  is  often  the  case, 
when  the  patient  approached  nearer  to  or  went  away  from  the 
wall.  This  may  be  due  to  the  fact  that  in  the  case  referred 
to  there  was  a  disturbance  in  the  mechanism  of  accommoda- 
tion. Although  the  apparent  size  of  the  hallucinatory  forms 
varies  with  their  projection  distance,  it  is  still  a  matter  of  doubt 
whether  the  patients  accommodate  as  the  distance  of  the  fig- 
ures changes. 

Hallucinations  of  hearing  are  the  most  common  form  of 
sense  deceptions  among  the  insane.  As  a  rule,  the  sensory 
vividness  of  auditory  hallucinations  is  even  greater  than  that 
of  the  visual.  A  patient  often  describes  visual  hallucinations 
as  pictures  or  visions,  and  they  seem  in  many  cases  to  lack 
the  stamp  of  reality  which  is  so  characteristic  of  the  auditory 
hallucinations.  One  of  the  distinguishing  features  of  audi- 
tory as  well  as  of  other  forms  of  hallucinations  is  frequently 
the  remarkable  reflex  power  they  exert  on  the  whole  psychic 
life  of  the  patient.  The  auditory  or  visual  hallucination,  char- 
acterized by  the  most  foolish  or  senseless  content,  may  domi- 
nate the  judgment  of  the  patient,  making  him  commit  insane 
or  dangerous  acts.  The  vividness  of  the  hallucinations  does 
not  alone  influence  conduct.  The  emotional  state  and  mood 
of  the  patient  are  of  prime  importance  and  may  even  deter- 
mine the  character  of  the  sensorial  phenomena.  Nor,  on  the 
other  hand,  is  the  power  of  the  hallucination  or  illusion  in 
determining  conduct  due  simply  to  its  persistence.  Many 
patients  who  are  chronically  insane  hear  voices  for  weeks  or 
months  at  a  time  without  acting  in  accord  with  the  sugges- 
tions or  the  commands  that  they  believe  are  whispered  or 

5 


66  PSYCHIATRY 

spoken  in  their  hearing.  And  yet  in  other  instances  within 
a  few  hours  these  same  patients  when  dominated  by  the  hallu- 
cinations may  commit  insane  acts. 

The  contents  of  hallucinations  vary  greatly,  but  it  not 
infrequently  happens  that  the  patient  sees  the  same  face,  hears 
the  same  voice,  smells  the  same  odor,  etc.  These  false  per- 
ceptions, which  remain  the  same  for  a  considerable  length  of 
time,  are  called  "  stabile  hallucinations." 

Auditory  hallucinations  are  not  uncommonly  found  to 
be  associated  with  disease  of  the  ear,  and  may  to  this  extent 
be  peripherally  conditioned.  Redlich  and  Kaufman28  ex- 
amined a  number  of  patients  who  suffered  from  auditory 
hallucinations  and  were  able  to  demonstrate  that  in  the  great 
majority  of  cases  there  were  lesions  in  either  the  middle  or 
inner  ear  that  acted  as  sources  of  chronic  irritation  to  the  audi- 
tory apparatus  and  gave  rise  to  various  elementary  sounds. 
These,  by  the  agency  of  a  hypersensitive  cortex,  were  readily 
transformed  into  more  complex  phenomena.29  The  effect  of 
peripheral  stimulation  under  certain  conditions  in  the  produc- 
tion of  visual  and  auditory  hallucinations  becomes  apparent  in 
the  cases  reported  by  Jolly,  where  the  latter  were  caused  in  an 
insane  patient  by  the  electric  stimulation  of  the  acoustic  nerve, 
and  by  Liepmann,  where  slight  pressure  on  the  eyeballs  in  an 
alcoholic  patient  caused  visual  hallucinations.  It  is  also  inter- 
esting to  note  that  removal  of  the  peripheral  exciting  cause 
may  be  followed  by  a  disappearance  of  the  hallucinations. 

Kahlbaum30  was  the  first  to  describe  the  so-called  reflex 
hallucinations.  Hallucinations  of  this  nature  are  due  to  the 
transference  of  a  stimulus  from  the  sensory  tract  upon  which 
it  first  impinges  to  another  where  it  awakens  a  response.  In 
one  case  described  by  Kahlbaum,  whenever  the  patient  saw  a 
stranger  he  heard  distinctly  the  derisive  name  "  Uncle  August." 

28  Ueber  Ohruntersuchungen  bei  Gehorshalluzinanten.  Wiener  klin. 
Wochenschr.,  1897. 

20  Bechterew :  Ueber  halluzinatorisches  Irresein  bei  Affectionen  des 
Gehororgans ;    Monatsschrift  f.  Psych,  u.  Neurol.,  Bd.  xiv,  H.  3,  1903. 

80  Die  Sinnesdelirien.  Allg.  Ztschr.  f.  Psych.,  Bd.  23,  S.  1-86. 


DISTURBANCES    OF    CONSCIOUSNESS  67 

Reflex  hallucinations  are  not  at  all  uncommon  and  are  ob- 
served in  a  great  variety  of  conditions.  They  may  occur 
singly  or  be  combined  with  disturbances  of  several  sense  areas. 
Combined  disturbances  of  sight  and  smell  are  very  common, 
especially  where  there  is  marked  interference  with  the  or- 
ganic sensations.  The  combination  of  hallucinations  of  hear- 
ing, sight,  and  touch  give  rise  to  the  ideas  associated  with 
the  most  serious  falsifications  of  the  patient's  environment 
and  personality. 

The  importance  of  fixation  or  the  direction  of  the  atten- 
tion to  certain  sense  areas  as  a  means  of  increasing  the  ten- 
dency to  the  formation  of  hallucinations  and  illusions  is  a 
well-known  fact.  In  certain  cases  if  the  patient's  attention  is 
directed  to  the  points  of  a  pair  of  compasses  pressed  against 
the  skin  paresthesias  and  tactile  illusions  may  develop.  A 
case  of  a  delirious  patient  has  been  reported  in  which,  when 
the  finger-tip  was  touched  with  a  pair  of  compasses,  the  points 
distant  six  millimetres  from  each  other,  two  sensations  were 
experienced.  But  when  the  points  were  brought  nearly  to- 
gether, the  patient  affirmed  that  he  was  touched  at  three  or 
four  points.  The  same  is  true  with  regard  to  the  testing  of 
vision.  If  the  patient  is  made  to  read  fine  print,  he  becomes 
conscious  of  anomalies  in  vision.  The  paralexia  may  develop 
as  the  size  of  the  print  is  changed.  In  delirium  it  is  sometimes 
noted  that  if  a  patient  be  permitted  to  look  at  a  picture  so  small 
that  the  whole  can  be  taken  in  at  a  glance,  the  visual  stimulus 
results  in  a  stationary  vision.  But  if,  on  the  other  hand,  he 
is  made  to  fix  upon  a  card  so  large  that  in  order  to  cover  the 
whole  field  a  movement  of  the  eyeballs  is  necessary,  fallacious 
sense  perceptions,  which  appear  to  move,  may  develop. 

IV.  DISTURBANCES    OF   CONSCIOUSNESS.31 

The  attempts  which  are  constantly  being  made  to  arrive 
at  a  single  accurate  definition  of  consciousness  have  at  present 

n  Von  Bechterew,  W. :  Bewusstsein  und  Hirnlokalisation.  Leipzig, 
1898.  Lipps,  Theodor :  Das  Selbstebewusstsein ;  Empfindung  und  Gefiihl. 
Wiesbaden,  1901.     Minot,  C.   S. :     The  Problem  of  Consciousness  in  its 


68  PSYCHIATRY 

no  practical  importance  for  the  physician.  From  a  clinical 
stand-point  the  general  description  of  the  phenomena  con- 
cerned, given  by  Loeb,  is  not  only  sufficient,  but  furnishes  us 
with  a  practical  working  hypothesis.  Associative  memory  or 
consciousness  may,  according  to  this  observer,  for  the  present 
be  assumed  to  be  the  mechanism  by  which  a  stimulus  brings 
about  not  only  the  effects  which  its  nature  and  the  specific 
structure  of  the  irritable  organ  call  for,  but  also  those  of 
other  stimuli  which  have  previously  acted  upon  the  organism 
or  which  are  acting  upon  it  simultaneously  with  the  stimulus 
in  question.  How  far  consciousness  is  to  be  considered  a 
factor  in  all  animal  life  is  a  question  that  does  not  concern 
the  clinician,  but  no  matter  how  conservative  may  be  his  view 
in  regard  to  its  universality,  for  man  at  least,  he  is  ready  to 
accept  Minot's  dictum  that  "  consciousness  stands  in  immediate 
causal  relationship  with  physiological  processes." 

If  we  view  consciousness,  in  a  general  way,  as  the  result 
of  a  series  of  established  relationships  between  the  cortical 
functions,  it  becomes  the  physician's  duty  to  seek  to  determine 
the  factors  that  may  derange  or  inhibit  these  processes. 

The  combination  of  the  various  mental  elements  or  inte- 
gers is  determined  by  the  needs  of  the  organism.  These  needs 
vary  during  different  periods  of  life,  not  only  at  the  important 
epochs,  but  from  day  to  day  and  even  from  hour  to  hour. 
The  equilibration  of  the  organism  when  it  has  been  disturbed 
by  reason  of  the  occurrence  of  a  new  need  is  again  restored 
as  soon  as  this  need  is  satisfied.  For  example,  a  sensation 
occurs  which  we  call  thirst;  the  need  of  water  is  felt.  Upon 
the  introduction  of  water  into  the  system  the  sensation  rapidly 
disappears.  In  a  general  way  the  duty  of  the  alienist  is  simi- 
lar to  that  imposed  upon  the  student  of  the  normal  functions 
of  the  brain.  Both  seek  to  determine  the  character  and  com- 
plexity of  the  needs  of  the  organism  and  to  understand  as 


Biological  Aspect.  Science,  1902,  vol.  xvi,  No.  392.  Oppenheimer,  Z. : 
Bewusstsein-Gefuhl.  Eine  psycho-physiologische  Untersuchung.  Wies- 
baden, 1903. 


DISTURBANCES    OF   CONSCIOUSNESS  69 

far  as  possible  the  manner  in  which  it  attempts  to  satisfy  them. 
When  the  combinations  which  are  brought  about,  as  the  result 
of  cerebral  activity,  between  the  various  mental  integers  reach 
a  certain  volume  and  degree  of  intensity,  they  are  collectively 
designated  consciousness.  This  term,  as  well  as  many  others 
in  the  psychological  dictionary,  is  relative,  and  a  separate  defi- 
nition must  be  found  for  each  case.  Roughly  speaking,  how- 
ever, we  may  affirm  that  the  various  processes  which  we  group 
together  under  this  head  bear  a  definite  relationship  to  each 
other,  so  that,  broadly  speaking,  the  consciousness  of  one  in- 
dividual under  normal  conditions  is  comparable  to  that  of 
another  person. 

Wernicke  distinguishes  between  the  mere  content  (Be- 
wusstseinsinhalt)and  the  activity  of  consciousness  (Bewusst- 
seinsthatigkeit)  and  has  further  proposed  a  threefold  division 
of  groups  of  functions,  forming  three  different  spheres  of  con- 
sciousness :  ( 1 )  those  functions  upon  which  the  ideas  of  self  or 
individuality  depend — autopsy  chic  consciousness;  (2)  those 
which  give  us  our  knowledge  regarding  our  own  bodies — 
somatopsychic  consciousness;  (3)  the  sensations  through 
which  is  revealed  to  us  the  external  world — the  allopsyche. 

This  tripartite  division  may  be  of  distinct  value  in  facili- 
tating clinical  descriptions.  Not  infrequently  we  meet  with 
forms  of  alienation  in  which  the  disturbances  in  consciousness 
are  limited  to  the  first  group,  so  that  we  have  an  autopsychic 
alienation.  Again,  the  disturbance  may  be  largely  in  the  group 
of  organic  sensations — the  somatopsychic  psychoses;  or  there 
may  be  anomalies  of  the  sensations  in  the  allopsychic  field  of 
consciousness — allopsychic  alienation.  In  the  majority  of 
cases  the  symptoms  are  connected  with  more  than  one  of  the 
three  spheres. 

The  various  complexes  associated  under  the  head  of  auto- 
psychic consciousness  possess  only  a  relative  stability  and  vary 
in  the  same  individual  at  different  epochs  of  life  and  even 
within  much  shorter  limits  of  time.  In  other  words,  the  sum 
total  of  the  sensations,  memories,  emotions,  etc.,  upon  which 
the  idea  of  personal  identity  rests  is  never  constant.     In  the 


70  PSYCHIATRY 

normal  individual  there  is  never  a  complete  dissolution  of 
all  these  factors  at  any  one  moment  except  during  periods  of 
unconsciousness  or  sleep.  Owing  to  the  absence  of  marked 
mutations  it  is  frequently  inferred  that  the  autopsychic  con- 
sciousness, or  knowledge  of  self,  is  comparatively  stable.  To 
a  certain  limited  extent,  it  may  be  said  that  self-consciousness 
is  independent  of  the  somatopsychic  and  allopsychic  fields  of 
consciousness.  There  are  many  forms  of  psychoses  in  which 
the  first  is  primarily  attacked.  One  of  the  best  known  ex- 
amples is  the  dissolution  of  the  personality  that  occurs  during 
the  course  of  dementia  paralytica. 

The  impairment  or  partial  inhibition  of  all  these  processes 
is  referred  to  as  a  dulling  or  clouding  of  consciousness.  These 
disorders  are  frequently  of  forensic  importance.  While  the 
cerebral  activities  upon  which  these  latter  functions  depend 
are  completely  inhibited,  the  action  or  actions  of  the  individual 
are  performed  unconsciously.  From  a  medico-legal  stand- 
point the  use  of  the  term  unconsciousness  does  not  imply  that 
no  reaction  follows  an  external  stimulus.  Persons  who  are 
subject  to  epilepsy  may  perform  a  series  of  complicated  acts 
during  an  attack.  As  is  well  known,  various  crimes  may  be 
committed  during  the  occurrence  of  these  transitory  disturb- 
ances. The  same  is  true  to  a  limited  extent  of  an  individual 
acting  under  the  influence  of  certain  drugs,  such  as  alcohol 
or  cocain. 

The  disturbances  in  consciousness  which  are  associated 
with  automatism  (poromania,  dromomania)  are  of  great  in- 
terest to  the  alienist  and  may  be  of  medico-legal  importance. 
Not  infrequently  during  periods  characterized  by  temporary  dis- 
turbances in  consciousness  patients  undertake  long  journeys. 
This  form  of  attack  has  often  been  considered  to  be  pathog- 
nomonic of  epilepsy,  but,  according  to  Schultz  and  others,32 
similar  automatic  acts  carried  out  during  a  period  character- 
ized by  marked  dulling  of  consciousness  are  met  with  in  other 

32Ueber  Krankhaften  Wandertrieb.     Allg.  Ztschr.  f.  Psych.,  1903,  Bd. 
lx,  H.  6. 


DISTURBANCES    OF   CONSCIOUSNESS  71 

forms  of  temporary  mental  aberration.  Such  actions  may 
appear  perfectly  normal,  and  yet  after  the  lapse  of  hours,  days, 
or  even  weeks,  when  the  patient  has  fully  regained  conscious- 
ness, the  memory  of  events  that  have  transpired  is  wanting. 
The  reason  why  a  patient  in  this  condition  should  undertake 
a  long  journey  is  not  at  all  clear.  Somewhat  similar  condi- 
tions have  been  known  to  be  associated  with  alcoholism,  cer- 
tain forms  of  degeneracy,  and,  according  to  v.  Krafft-Ebing, 
even  with  neurasthenia.  It  is  interesting  to  note  that  in  many 
of  the  cases  reported  the  patients  remember  that  they  felt 
badly  just  prior  to  starting  on  the  journey.  In  some  instances 
there  is  a  pronounced  apprehensiveness  and  occasionally  a 
feeling  of  oppression  in  the  precordial  region.  In  others  the 
sensation  is  more  general  and  is  also  accompanied  by  suspi- 
cion, depression,  and  in  some  instances  a  tendency  towards  a 
general  irritability.  The  amnesia  in  these  cases,  as  would  be 
expected,  is  nearly  always  marked. 

Reference  has  already  been  made  to  the  relative  stability 
of  the  content  of  the  normal  field  of  body  consciousness 
(coensesthesia)  and  to  some  of  the  more  important  changes 
which  may  give  rise  to  various  anomalies.  Head  and  others 
have  recently  called  attention  to  the  important  part  that  diseases 
of  the  internal  viscera  play  in  changing  the  normal  content.33 
The  lower  we  go  in  the  animal  scale  the  more  important  the 
visceral  impulses  seem  to  be  in  determining  the  actions  of  the 
individual.  But,  as  Head  has  shown,  in  the  normal  healthy 
individual  these  are  kept  in  the  background,  whereas  during 
disease  the  organic  sensations  may  become  so  prominent  and 
insistent  as  to  be  important  in  determining  action.  These 
abnormal  intrusions  into  the  field  of  consciousness  may  be  the 
starting-point  of  various  moods  and  mental  anomalies. 

Changes  in  the  organic  sensibility  may  assume  a  great 
variety  of  forms  and  as  yet  have  not  received  sufficiently  close 
attention  and  study   from  physicians.      Not   infrequently   in 

33  Certain  Mental  Changes  that  accompany  Visceral  Diseases.     Brain, 
1901,  p.  345- 


J2.  PSYCHIATRY 

the  early  stages  of  alienation  we  meet  with  marked  disturb- 
ances in  the  ordinary  sensations  resulting  in  an  abnormal  sense 
of  fatigue.  This  is  particularly  marked  in  the  neurasthenic 
and  hysterical  states  or  in  the  beginning  periods  of  depression. 
The  patients  affirm  that  they  cannot  make  the  slightest  effort 
without  experiencing  a  feeling  of  utter  weariness.  In  other 
cases,  particularly  the  earlier  stages  of  intoxication  and  in  the 
incipient  phase  of  manic  excitement,  the  patient  is  able  to 
carry  through  a  great  variety  of  undertakings  without  experi- 
encing a  sense  of  effort.  An  important  symptom  in  the  diag- 
nosis of  the  early  stages  of  mania  is  the  apparent  tirelessness 
of  the  patients,  who  never  seem  to  weary  although  almost 
constantly  in  motion.  Important  changes  in  the  organic  sensi- 
bility are  further  noted  in  connection  with  the  feeling  of  thirst 
or  hunger.  In  many  instances  the  satisfaction  which  follows 
the  drinking  of  fluids  or  the  taking  of  food  seems  to  be  absent, 
and  the  patient  consumes  large  quantities  of  meat  and  drink  ap- 
parently without  experiencing  any  sense  either  of  satisfaction 
or  of  discomfort. 

Some  of  these  points  are  well  illustrated  by  the  following 
extracts  from  the  histories  of  cases,  for  which  I  am  indebted 
to  my  friend,  Dr.  Cary  B.  Gamble,  Jr. 

Case  I.  Asthma,  emphysema,  impairment  of  attention  and  memory 
with  fear.  Female,  aged  50.  Woman  of  considerable  intelligence  and  edu- 
cation. For  thirty-five  years  has  been  subject  to  attacks  of  asthma,  as  a 
result  of  which  there  is  a  decided  amount  of  emphysema.  Three  years  ago 
at  the  time  of  the  attacks  the  patient  began  to  suffer  from  a  considerable 
amount  of  referred  pain  located  anteriorly  in  the  upper  portion  of  the 
chest  and  posteriorly  under  the  left  shoulder-blade.  About  the  same  time 
she  began  to  complain  of  an  indefinite  apprehensiveness  without  any  well- 
defined  fear.  This  feeling  usually  precedes  her  asthmatic  attacks.  Asso- 
ciated with  it  there  is  considerable  diminution  in  the  power  of  attention 
and  memory. 

The  following  case  shows  a  slightly  greater  change  in 
the  field  of  body  consciousness. 

Case  II.  Female,  aged  30.  Mitral  stenosis  with  failing  compensa- 
tion. This  patient  also  had  an  area  of  referred  pain  on  the  left  side  of 
her  chest,  which  extended  over  the  epigastrium  to  the  hepatic  region.    At 


DISTURBANCES    OF   ASSOCIATION  73 

times  the  pain  increased  greatly  in  severity,  and  was  associated  with  some 
mental  depression.  At  these  periods  she  also  became  suspicious  of  those 
about  her,  affirmed  that  the  nurses  neglected  her,  and  the  doctors  thought 
she  was  malingering.  These  moods  were  transitory,  and  the  patient  was 
able  to  appreciate  their  significance. 

Case  III  is  of  interest,  as  the  patient  showed  signs  not  only  of  de- 
pression, but  of  some  exaltation.  Woman,  aged  35,  who  had  suffered  from 
an  attack  of  rheumatism.  On  admission  to  the  hospital  she  was  found 
to  be  suffering  from  shortness  of  breath,  cough,  cedema  of  the  extremities, 
and  cyanosis,  with  superficial  pain  and  tenderness  over  the  left  breast  and 
back.  Marked  evidences  of  mitral  stenosis.  She  was  subject  to  attacks 
of  depression,  followed  by  a  marked  sense  of  physical  exaltation. 

Case  IV.  The  patient,  who  had  signs  of  adherent  pericardium,  was 
subject  to  alternating  periods  of  depression  and  exaltation  and  auditory 
hallucinations.  For  a  year  prior  to  admission  to  the  hospital  she  had  fre- 
quently been  awakened  at  night  by  hearing  the  sound  of  a  bell,  which 
seemed  to  continue  for  about  fifteen  minutes.  At  first  she  thought  that 
the  noise  was  real,  but  finally  concluded  that,  as  there  were  no  bells  in  the 
neighborhood,  the  sound  was  merely  subjective  in  character.  The  hal- 
lucinations always  became  more  pronounced  after  a  severe  cardiac  attack. 
Hearing  was  unusually  acute,  and  there  was  no  evidence  of  thickening  or 
retraction  of  the  ear-drums. 

V.  DISTURBANCES    IN    THE    FUNCTIONS    OF    ASSOCIATION. 
INTERFERENCE   WITH    THE    EXPRESSION    OF    CON- 
NECTED  THOUGHT.      ANOMALIES    OF   MEM- 
ORY.   DISTURBANCE  IN  ORIENTATION. 

All  forms  of  thought  involve  an  association  or  connection 
between  the  various  constituent  psychic  elements  or  units. 
The  evidence  of  this  synthesis  becomes  more  apparent  in  what 
is  called  connected  thinking.  Regarding  the  neural  states  or 
processes  which  determine  these  combinations  practically  noth- 
ing is  known. 

The  doctrine  of  associationism,  so  frequently  enunciated, 
explains  neither  the  sequences  nor  the  variations  in  the  thought 
processes.  The  mere  fact  that  certain  combinations  of  speech 
suggest  mere  time  or  spatial  contiguity  of  ideas  cannot  be 
regarded  as  an  explanation  of  the  phenomenon.  The  assertion 
is  frequently  made  that  contiguity  in  place  or  time  as  well  as 
the  factors  of  similarity  and  the  law  of  cause  and  effect  explain 
the  phenomena  of  the  flow  of  thought.  But  the  mere  observa- 
tion and  recording  of  what  are  believed  to  be  prominent  fea- 


74  PSYCHIATRY 

tures  of  associations  cannot  give  any  real  insight  into  the 
neural  conditions  which  are  at  the  basis  of  the  phenomena. 

Clinical  observations  have  shown  that  the  character  and 
complexity  of  the  synthetic  processes  may  be  essentially 
changed  during  the  course  of  an  alienation.  It  may  be  said  of 
the  abnormal  as  of  the  normal  processes  that  the  needs  of 
the  organism  determine  the  character  of  the  association;  but 
it  is  true  only  in  a  general  sense  in  cases  of  alienation,  as 
compared  with  normal  states,  that  the  complexity  and  char- 
acter of  the  combinations  are  capable  of  modification.  This 
modification  is  one  of  degree  and  not  of  kind.  The  power 
of  association  or  combination  is  as  truly  a  function  of  the 
organism  as  is  memory  or  the  faculty  of  reproducing  a  former 
impression.  The  expression  of  thoughts  in  speech  or  writing 
is  determined  by  needs  created  by  individual  necessities,  by 
education,  and  other  factors.  The  recollection  or  remembrance 
of  an  impression  once  stamped  upon  the  neural  elements 
awakens  a  train  of  thought  or  action  which  may  have  been 
previously  repeated  countless  times. 

As  a  rule,  it  is  only  the  marked  deviations  from  these  set 
forms  which  attract  the  attention  of  the  alienist.  A  train  o£ 
thought  as  well  as  of  action  in  the  normal  individual  is  directed 
towards  a  certain  definite  end;  in  other  words,  it  is  purpose- 
ful. All  subsidiary  processes  are,  as  a  rule,  repressed  or  in- 
hibited. One  of  the  fundamental  characteristics  of  mental 
disturbances  associated  with  conditions  of  exhaustion  or  fa- 
tigue is  the  undue  modification  of  the  minor  processes.  The 
psychic  activity  is  no  longer  dirigible.  The  subsidiary  proc- 
esses are  intensified,  and,  to  use  an  every-day  expression,  the 
patient's  mind  wanders.  Minor  and  lateral  associations  divert 
the  train  of  thought  or  action.  The  combinations  between  the 
various  mental  elements  chosen  now  become  those  that  are 
the  simplest  and  easiest  for  the  patient  to  form,  regardless  of 
sense.  For  this  reason,  mere  sound  associations  or  those  that 
have  become  common  through  constant  repetition  may  pre- 
dominate. 

Similar  disturbances  in  association  are  particularly  marked 


DISTURBANCES    OF   ASSOCIATION  75 

following  too  large  doses  of  cocain  or  alcohol.  They  also 
occur  in  the  early  stages  of  paresis,  in  dementia  prsecox,  and 
in  certain  organic  brain  diseases.  In  cases  of  maniacal  excite- 
ment the  disturbances  in  both  speech  and  writing  often  present 
certain  characteristic  anomalies.  In  addition  to  the  exaggera- 
tion of  what  in  the  normal  individual  are  the  subsidiary  proc- 
esses, the  tendency  to  form  sound  associations  is  marked.  The 
patient's  train  of  thought  is  not  guided,  as  it  normally  should 
be,  by  the  end  to  be  attained  (Zielvorstellung).  There  is  a 
marked  tendency  to  give  verbal  expression  to  every  idea,  and 
his  own  volubility  serves  reflexly  to  divert  the  patient's  atten- 
tion. In  maniacal  patients  the  speech-compulsion  exhibited 
may  become  a  dominant  symptom,  and  is  frequently,  though 
by  no  means  always,  increased  in  proportion  to  the  degree  of 
psychomotor  irritability  present. 

Aschaffenburg34  has  affirmed  as  a  result  of  his  observa- 
tions that  during  the  period  of  excitement  which  is  character- 
istic of  the  manic-depressive  insanity  there  is  a  dissociation 
of  ideas.  The  interval  of  time  between  the  incidence  of  the 
auditory  stimulus  and  the  motor  reaction  is  shortened,  and 
this  is  one  of  the  reasons  why  the  only  combinations  that  occur 
are  likely  to  be  those  which  are  the  easiest  for  the  patient  to 
form,  irrespective  of  the  content  or  logical  sequence  of  the 
ideas. 

There  is  also  a  predisposition  on  the  part  of  patients 
in  this  condition  to  the  formation  of  combinations  in  which  a 
certain  rhythm  or  cadence  is  present.  Not  infrequently  this  is 
seen  in  the  proneness  of  certain  of  these  individuals  to  make 
verses.  In  these  cases  there  is  also  a  marked  tendency  towards 
pure  sound  association  and  the  bringing  together  of  senseless 
syllables.  From  certain  observations  the  inference  has  been 
drawn  that  the  tendency  to  sound  association  is  indicative  of 
an  increased  psychomotor  activity.     Bonhoeffer,  however,  far 


M  Experimentelle  Studien  iiber  Associationen.  III.  Theil.  Die  Ideen- 
flucht.  Psychologische  Arbeiten.  her.  v.  Kraepelin,  Bd.  iv,  H.  2,  Leipzig, 
1902,  S.  235. 


j6  PSYCHIATRY 

from  rinding  this  tendency  marked  in  delirious  cases  with 
motor  restlessness,  noted  that,  on  the  contrary,  the  content  of 
the  delirium  did  not  differ  essentially  from  the  association  in 
normal  individuals;  that  is  to  say,  associations  determined  by 
the  sensations  preponderated.  It  has  also  been  observed  that 
in  cases  of  mental  depression  with  accompanying  anxiety,  but 
without  motor  agitation,  there  is  a  complete  independence  of 
the  two  phenomena.  The  attention  of  the  patient  is,  as  a  rule, 
easily  gained,  but  is  almost  as  readily  deflected. 

It  is  unfortunate  that  the  term  "  flight  of  ideas"  so  com- 
monly used  by  alienists  is  capable  of  so  many  various  inter- 
pretations. Kraepelin  uses  the  expression  to  describe  a  symp- 
tom-complex which  is  met  with  in  cases  of  manic-depressive 
insanity  and  in  certain  forms  of  asthenic  psychoses.  The 
absence  from  the  speech  of  the  patient  of  a  definite  directing 
motive  is  characteristic  of  the  disturbance.  The  prominence 
of  the  subsidiary  associations,  which  in  normal  conditions  are 
kept  in  abeyance,  is  noticeable,  as  well  as  the  fact  that  external 
impressions  or  stimuli  serve  to  deflect  the  train  of  thought.  In 
this  sense  the  typical  flight  of  ideas  consists  in  a  combination 
of  symptoms  which  may  be  successfully  analyzed.  In  the 
first  place,  we  have  to  do  with  what  has  been  termed  an  ex- 
ternal flight  of  ideas  in  which  extra-organic  stimuli  give  the 
trend  to  the  flight.  Here  the  association  is  not  determined  by 
the  actual  content.  In  the  so-called  inner  flight  of  ideas 
rhyming  and  association  by  assonance  may  be  prominent  fea- 
tures. In  addition,  ideas  keep  cropping  up  in  consciousness 
and  in  a  measure  determine  succeeding  expressions.  As  a 
rule,  the  actual  rapidity  with  which  combinations  are  formed 
during  the  period  of  manic  excitement  is  not  increased.  This, 
however,  is  not  in  accordance  with  the  opinion  of  those  who 
report  a  definite  quickening  of  the  association  processes  under 
such  circumstances.  Ziehen  contends,  on  the  contrary,  that 
during  the  period  when  there  is  a  rapid,  steady  flow  of  ideas 
there  is  a  synchronous  increase  in  the  attention  which  he  refers 
to  as  hyperprosexia.  Closer  clinical  analysis  reveals  the  fact 
that  there  is  in  a  large  majority,  if  not  in  all,  of  the  cases  a 


DISTURBANCES    OF   ASSOCIATION  77 

propensity  towards  an  actual  splitting  up  of  the  attention.  As 
the  manic  excitement  increases,  the  sound  associations  become 
more  and  more  dominant.  A  parallelism  exists  in  some  in- 
stances between  the  flight  of  ideas  and  the  psychomotor  irri- 
tation, but  this  feature  is  not  constant.  A  typical  "  flight  of 
ideas"  may,  on  the  one  hand,  be  associated  with  a  general 
psychomotor  inhibition,  while  instances  are  not  infrequent 
where  the  motor  restlessness  may  be  present  without  the 
"  flight  of  ideas." 

Heilbronner35  criticises  Aschaffenburg's  deductions,  and 
affirms  that  the  phenomena  noted  as  the  result  of  experiments 
have  not  been  substantiated  by  clinical  observations,  and  main- 
tains that  the  rapidity  of  the  combining  processes  is  actually 
increased.  Moreover,  he  affirms  that  the  flight  of  ideas  is 
independent  of  the  speech  compulsion.  Wernicke  attempts  to 
establish  an  intimate  causal  relationship  between  these  two 
symptoms  and  the  intrapsychic  hyperfunction ;  the  latter  is 
supposed  to  bring  about  an  actual  levelling  (Nivellirung)  of 
ideas.  Ziehen  affirms  that  the  motor  agitation  and  the  flight 
of  ideas  are  coordinated  and  determined  merely  by  an  abnor- 
mal rapidity  in  the  combining  processes,  and,  further,  that 
there  is  an  actual  spread  of  the  cortical  irritation  chiefly  in- 
volving the  motor  regions. 

Liepmann36  expresses  dissent  from  the  views  enunciated 
by  Aschaffenburg  to  the  effect  that  the  disturbance  of  con- 
ceptual thought  in  cases  of  maniacal  excitement  is  a  secondary 
phenomenon.  He  also  maintains  that  the  increase  in  the  rap- 
idity of  the  associative  process  is  apparent  rather  than  real, 
and  is  essentially  a  pure  motor  phenomenon.  Three  facts, 
according  to  Liepmann,  militate  against  the  views  of  Aschaf- 
fenburg :     ( 1 )    The  patients   not   infrequently   describe  their 

35  Heilbronner,  Karl :  Ueber  epileptische  Manie  nebst  Bemerkungen 
ueber  die  Ideenflucht.  Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  xiii,  H.  3  and 
4,  1903,  S.  193. 

36  Neurolog.  Centralbl.,  Mai  1,  Nr.  9,  1903,  "  Ueber  Ideenflucht." 
Sammlungzwanglose  Abhandl.  aus  d.  Gebiete  d.  Nerv.  u.  Geisteskrankhei- 
ten,  Halle,  1904. 


78  PSYCHIATRY 

hallucinations  in  a  manner  which  suggests  a  flight  of  ideas, 
but  which,  on  close  analysis,  is  found  to  be  essentially  differ- 
ent. This  phenomenon  may  be  unaccompanied  by  any  motor 
excitement.  (2)  The  sound  associations  fail  in  certain  cases 
in  which  there  is  a  definite  flight  of  ideas.  (3)  In  catatonic 
periods  intense  motor  excitement  sometimes  occurs  unaccom- 
panied by  any  flight  of  ideas. 

The  observations  may  be  summarized  as  follows :  Nor- 
mally a  train  of  thought  is  characterized  by  an  advance  or 
progression  of  the  ideas  in  a  definite  direction.  In  the  phe- 
nomenon under  discussion  a  deflection  of  both  the  normal 
sensory  and  associative  processes  occurs,  so  that  a  definite 
guiding  principle  determining  the  sequence  of  thought  is  ab- 
sent. There  is  a  deflection  of  attention  as  well  as  impairment 
of  the  understanding.  In  normal  connected  thought  the  chief 
object  of  the  attention  is  focussed  upon  independently  of  the 
subsidiary  and  minor  facts  of  consciousness.  The  less  intense 
this  focussing  becomes,  the  greater  is  the  inclination  towards 
the  dissolution  of  the  train  of  thought.  If  the  chance  appear- 
ance of  a  representation  in  the  focus  of  consciousness  is  deter- 
mined merely  by  a  transitory  connection  or  by  a  sensory  stimu- 
lus, the  conditions  are  ripe  for  an  excessive  flight  of  ideas. 
Liepmann  affirms  that  in  cases  in  which  the  flight  of  ideas  is 
well  marked  there  is  always  a  rapid  change  in  the  represen- 
tations brought  within  the  focus  of  the  attention.  This  should 
not  be  considered  to  be  identical  with  an  actual  increase  in  the 
rapidity  of  association.  Although  the  flight  of  ideas  is  fre- 
quently associated  with  the  symptoms  of  psychomotor  irrita- 
bility, it  is,  nevertheless,  to  be  regarded  as  an  intrapsychic  dis- 
turbance. 

The  following  extract  from  the  history  of  a  case  of  manic- 
depressive  insanity  serves  to  illustrate  the  "  flight  of  ideas." 

The  patient  was  very  restless  and  talked  excitedly  as 
follows  (verbatim  report  in  short-hand)  : 

"  George  A.  was  there.    James  and  William  as  if  risen  from  the  dead. 

Fort  got  sick.    Where  are  you  in  waiting,  William?    Colonel  X comes 

up  and  registers.     Where  am  I?     Jesus  Christ!     I  will  be  in  time  now, 


DISTURBANCES    OF   ASSOCIATION  79 

I  know  it.    Dr.  C was  so  good,  but  he  did  not  know  his  business.     I 

forgive  him.     Now,  there  is  John.     I  would  like  to  see  Mr.  Z .     I 

think  I  understand  him.  That  looks  like  John.  Mother  is  coming.  I 
took  the  brass  bead  of  the  rosary,  and  I  pressed  it  to  my  lips  and  kissed 

it.    Now  it  comes  to  Captain  Jinks ;   that's .     Now,  you  bring  me  back 

again — that  is  mother  there;  now  there's  George;  and  where  you  get  to 
George,  he  is  one  of  the  best  friends  I  had  in  the  world;    he  had  an 

abscess  in  the  ear,  I  believe.     Mr.  Z came  to  the  house,  and  I  like 

him.  I  got  my  wisdom  teeth  cut ;  now  it  is  great.  This  was  due  to  a 
run-down  system,  and  if  I  must  say  it — Tom  knows  all  about  that.     Now 

first  comes .     How  many  children  have  you  got  ?     I   asked  for  my 

brother  George,  who  you  know  had  an  abscess  in  the  ear.     Now,  it  is 

the  first  success  of  the  Catholic  Church.    Now,  there  is  Mr.  N ,  whom 

I  stood  for — collar  buttons.    And  as  soon  as  I  got  in  there  I  saw  George 

A .     Our  Father  who  are  in  Heaven,  hallowed  be  Thy  name — and  I 

never  understood  what  I  meant.     That  man  coming  round  there  was  in 

Dr.  C 's  house  I  believe.    Wait  a  minute,  yes,  that  is  mother  with , 

and  she  was  A-n-n-i-e.     Now,  there  is  George  A and  Dr.  C ;    he 

was  my  friend.  I  took  the  prussic  acid,  and  I  took  the  brass  bead,  and 
when  we  came  to  George  A it  was  tally,  tally." 

Replies  to  questions: 

Q.  Why  can't  you  keep  still  ? 

A.  Because  I  am  nervous,  because  I  must.  Now  I  am  coming  around 
to  Dr.  , 

Q.  Mr.  C ,  can't  you  keep  still? 

A.  I  will  try  to  keep  still.    Well,  where  is ? 

Q.  Tell  me,  Mr.  C ,  why  you  can't  keep  still. 

A.  Because  I  had  no  business  to  behave  the  way  I  did. 

Q.  Can't  you  keep  still,  Mr.  C ? 

A.  Well,  I  am  trying. 

Q.  Can't  you  keep  still  without  talking? 

A.  Yes. 

Q.  Let  me  see  how  long  you  can  do  so  ? 

(Temporary  silence  for  a  few  seconds;  then  the  patient  begins  as 
follows:) 

Where  is  George  A ? 

Examiner:     Can't  you  keep  quiet? 

(Silence  for  a  longer  period.) 

There  is  George  A right  there,     —that  is  ,  certainly  it  is. 

Q.  Mr.  ,  why  do  you  talk  so  foolishly? 

A.  I  want  to  see  Dr.  . 

Q.  Who  am  I?     (Examiner  refers  to  himself.) 

A.  I  do  not  know;    is  that  Dr.  ? 

Q.  Where  are  we? 

A.  Well,  do  the  best  you  can. 

Q.  Mr. ,  where  are  we? 

A.  We  are  in  the  Antipodes. 

Yes,  what  is  the  matter  with  the  physician— what  is  the  trouble  ? 


80  PSYCHIATRY 

Q.  What  is  the  trouble  with  you,  Mr.  C ? 

A.  I  am  in  bed  sick  with  a  run-down  system. 

"  Now  we  are  coming  back.  We  are  risen  from  the  dead  with  Jesus, 
the  first  success.    A-n-n-i-e.    Now  we  are  getting  around  again.    There  is 

the  shorthand  writer.     Now  just  go  to  dear  old  and  say  that  this 

is  the  first  success  of  Marconi  in  Jesus,  and  he  knows  of  the  woman, 
because  I  did  take  the  brass  beads  from  mother ;    came  to  the  house,  and 

I   think  Dr.  he  came.     George   A is   a  great   friend  of  mine; 

certainly  he  is." 

The  following  is  an  example  of  a  mild  flight  of  ideas  as 
expressed  in  writing.  The  patient  was  asked  to  give  an  ac- 
count of  his  case  to  the  doctor. 

"  My  Dear  Doctor  :  I  want  to  give  you  an  exact  statement  of  my  case 
since  you  left  me,  out  of  the  Room  yesterday  morning  and  it  will  be 
brief.  I  took  a  long  walk  with  my  good  young  attendant,  ate  a  big  din- 
ner, drank  4  glasses  of  milk  and  lots  of  water,  the  trouble  I  reported  to 
you  has  entirely,  or  nearly  so  disappeared.  I  then  slept  for  two  and  one 
half  hours  so  my  attendant  informs  me,  from  about  2.30  to  5  P.  M.  then  I 
went  out  until  supper  time,  ate  a  large  supper,  saw  you  later  on  in  the 
evening,  after  taking  another  rest  in  bed  for  y2  hour.  Read  everything  I 
could  in  a  short  time,  walked  up  and  down  the  long  halls,  talked  to  every 
one  that  cared  to  open  conversation,  by  invitation  played  uchre  with  a 
man  from  the  south  with  his  hands  done  up  in  bandages  and  he  beat  me 
hands  down  at  the  game  of  his  choice.  Then  I  talked  until  almost  bed 
time  with  him  and  that  big  fellow  220  lbs.  who  says  he  takes  a  glass  of 
beer  to  make  him  sleep.  How  foolish.  I  told  him  how  to  go  to  sleep  with- 
out any  aid  and  he  tells  me  this  morning,  although  I  suppose  he  took  his 
beer,  that  he  slept  splendidly.  I  slept  soundly  from  about  10  until  sometime 
in  the  night  when  I  requested  the  attendant  to  get  me  a  glass  of  water  and 
a  cup  of  beef  tea  with  lots  of  red  pepper.  /  awoke  at  3  o'clock,  my  shirt  is 
shamefully  soiled  and  my  collar  size  15  is  much  the  worse  for  wear,  can 
I  have  a  clean  shirt  and  collar  this  morning? 

"  You  will  see  from  the  above  that  I  have  slept  from  2  P.  M.  yesterday 
to  6  A.  M.  total  16  hours  2.30  ten  and  a  half  hours 
2 
6 


10.30 

any  more  would  be  very  apt  to  give  me  a  dull  headache  such  as  my  brother 
sisterinlaws  and  mother  constantly  complain  of. 

"  I  am  no  doubt  very  very  mad  as  they  all  think  excepting  only  B ■ 

and  C who  are  both  reasonable  beings  it  is  no  fault  of  theirs : —  they 

were  born  that  way  and  can't  help  it — so  were  you  and  I — '  Got  helf  uns 
wir  con  nicht  on  ders'  as  Martin  Luther  said  when  driven  by  others 
to  make  the  present  remark.     I  have  certainly  written  you  enough  to  con- 


ANOMALIES    OF    MEMORY  gl 

vince  you  of  my  crossness  but  they  still  believe  me  '  Mad'  you  don't  now 
help  me  to  carry  on  the  joke  and  assist  me  to  show  them  '  some  day'  in 
the  far  distant  future  that  I  was  made  but  with  one  method  without 
madness. 

"  Please  send  me  any  old  clean  shirt  and  collar  before  breakfast  size 
15.  Telephone  my  brother  not  to  come  to  see  me  yet  as  he  irritates  me. 
To  go  home  and  look  after  his  own  family  and  mind  his  own  business 
Send  me  the  watch  he  promised  me,  all  the— papers  daily  all  important 

and  social  mail  and  see  that  X buys  all  the  Farm  and  the  tract  with 

the  elm  trees  on  it  and  do  all  such  other  things  that  will  please  me  and 
report  progress.     Then   send  immediately  by  telephone   or  let  me   do   it 

for  the  only  people  that  fought  with  me  until  W and  the  dercetives 

arrived. 

(3)  and  please  send  for  them  immediately  and  tell  them  all  to  come  to- 
gether and  give  me  all  the  things  that  will  minister  to  my  comfort  and 
happiness. 

"  Thanking  you  always  for  your  kindness  and  that  you  have  not 
(2)  given  me  any  delays  I  am 

"  Very  sincerely, 
"A.  B. 
"  Mad  man  behind  the  bars  of  good  fortune 
Have  my  mail  addressed  not  to  the  lock  post-office  and  not  to 
(I)  the  institution  for  my  bankers  credit  sake. 

1  ~  "T?  gf  thC  imP°rtant  features  of  this  letter  read  onlv  this  many  the 
letter     backwards    as  all  good  books   should  in  my  estimation  be   read. 
Paragraphs     1)    (2)    (3)    (4)  and  then  Iet  me  take  a  j         ^  ^ 
attendant  early  this  morning  and  give  me  a  parole  later  on." 

ANOMALIES  OF  MEMORY.37 
The  power  of  the  organism  to  retain  and  redevelop  im- 
pressions is  probably  to  be  regarded  as  a  specific  function. 
That  so-called  memories  are  localized  in  individual  cells  is 
an  hypothesis  which  must  be  abandoned,  and  although  the 
problem  is  one  which  lies  within  the  realm  of  brain  phvsiology 
it  must  be  confessed  that  little  is  known  regarding  the  dynam- 
ics of  the  processes  concerned  in  the  reproduction  and  re-collec- 
tion  of  past  stimuli.  At  present  it  is  sufficient  for  the  clinician 
to  recognize  that  the  function  or  functions  grouped  together 

*vJUeriJ'^.:  °n  Memory  and  the  Specific  Energies  of  the  Nervous 
bystem  2d  edition,  Chicago,  1897.  Loeb,  J.:  Comparative  Physiology  of 
the  Bram  and  Comparative  Psychology.     New  York  and  London,   1900. 

Memorv)  n'  ''  ^f^  °f  P™050^  and  Psychology  (Chapter  on 
memory).    New  York  and  London,  1902. 

6 


82  PSYCHIATRY 

under  the  head  of  memory  are  specific  characteristics  of  the 
organism. 

For  convenience  sake  the  various  functions  of  memory 
have  been  arbitrarily  divided  into  three  categories — those  of 
reproduction,  recognition,  and  localization.  But  the  utiliza- 
tion of  this  division  is  not  in  any  way  meant  to  convey  the 
idea  that  these  functions  are  separate  and  distinct,  as  it  is 
well-nigh  impossible  to  conceive  of  one  series  of  phenomena 
taking  place  without  the  reciprocal  action  of  a  second  or  third. 
From  the  clinical  stand-point  there  is  no  reason  why  defects 
in  these  various  functions  may  not  be  considered  as  either 
general  or  special  in  character.  As  an  example  of  the  first 
group  may  be  cited  the  general  impairment  in  all  forms  of 
associative  memory  without  the  existence  of  pronounced  de- 
fects in  certain  directions.  This  phenomenon  is  commonly 
observed  in  a  great  variety  of  psychoses  in  which  there  is  a 
pronounced  general  mental  enfeeblement.  In  the  special  or 
more  or  less  isolated  defects  the  power  of  reproducing  certain 
images  or  impressions  is  lost  while  others  are  retained.  From 
the  clinical  stand-point  and  to  facilitate  description  we  may 
also  speak  of  a  general  amnesia — a  term  used  to  indicate  the 
general  lack  of  retentiveness — or  a  paramnesia,  in  which  dis- 
turbance in  the  mechanism  of  associative  memory  causes  a 
distortion  and  false  association  of  the  retained  facts.  And 
finally,  according  to  some  authors,  there  is  a  hypermnesia, 
in  which  there  is  an  apparent  increase  in  intensity  and  bril- 
liancy of  certain  mental  reproductions  or  re-collections. 

All  these  various  psychical  processes,  which  we  collect- 
ively designate  as  memory,  may  become  seriously  disorganized 
during  an  attack  of  alienation.  On  account  of  the  great  com- 
plexity and  interaction  of  the  processes,  it  is  necessary  that 
they  should  be  considered  in  their  relationship  to  other  psychi- 
cal phenomena.  There  are,  however,  certain  characteristics 
associated  with  these  processes  which  are  of  particular  interest 
to  the  clinician.  In  the  first  place,  there  is  the  recording  fac- 
ulty, or  power  of  retaining  a  new  impression  (Wernicke's 
Merkfahigkeit).  ■  Next  in  importance  comes  the  capacity  to 


ANOMALIES    OF   MEMORY 


83 


reproduce  this  impression,  and  this  is  directly  dependent  not 
upon  one  but  upon  a  number  of  functions.     And  finally  there 
is  the  tendency  shown  by  the  brain  to  re-collect  and  reproduce 
impressions  after  varying  intervals  of  time.     As  has  already 
been  pointed  out,   these  functions   are  dependent  upon  each 
other  and  are  intimately  related  to  other  processes.     In  the 
various  disturbances  which  are  common  in  the  insane  they  do 
not  suffer  equally.    The  facts  bearing  upon  the  genesis  of  these 
functions  have  a  clinical  value.     If  we  consider  the  develop- 
ment of  the  memory  in  the  child,  it  is  apparent,  as  Spiller  has 
affirmed,38  that  this  is  determined  by  the  needs  of  the  indi- 
vidual.    In  the  infant  at  birth  many  of  the  muscular  move- 
ments are  incoordinated  and  performed  with  difficulty.     Con- 
stant repetition  develops  the  power  to  reproduce  movements 
with  increased  ease  and  celerity.     This  exercise  or  muscular 
memory  develops  rapidly  in  response  to  various  intra-  and 
extra-organic  stimuli.     The  return  to  the  primitive  state  of 
the  child,  where  the  simplest  movements  are  reproduced  with 
difficulty,  is  not  infrequently  seen  in  certain  forms  of  aliena- 
tion, particularly  in  the  catatonic  states  and  in  the  dementias. 
Next  in  order  comes  the  retention  memory  or  the  feeling  of 
recognition.    By  some  clinicians  this  form  of  memory  or  sense 
of  recognition   is   held   to   be   a  definite  and  distinct   factor. 
Vogt  has  affirmed  that  with  every  perception  there  is  associated 
an  impression  of  recognition,  and  not  only  are  the  clearness 
and  plainness   of  the  memory  picture  essential   factors,   but 
coupled  with  them  is  a  definite  and  distinct  quality  called  the 
recognition  faculty   (Bekanntheitsgefiihl).     Pick  affirms  that 
this  factor  is  important  in  analyzing  the  symptoms  in  various 
forms  of  alienation.     He  contends  that  the  feeling  of  strange- 
ness and  the  inability  of  individuals  in  certain  states  to  recog- 
nize either  their  surroundings  or  familiar  faces  are  directly 
referable  to  abnormalities  of  the  recognition  faculty.     Rosen- 
bach39  reported  the  case  of  a  man  who  had  never  suffered 


Op.  cit. 

Ellenmeyer's  Centralblatt,   1886,  Nr.  7. 


84  PSYCHIATRY 

from  symptoms  of  alienation  until  one  day  after  very  severe 
exertion,  when  he  failed  utterly  to  recognize  the  street  in 
which  he  had  lived  for  years  and  greeted  perfect  strangers 
as  intimate  friends.  It  was  possible,  however,  to  convince 
the  patient  of  his  error.  In  hysterical  and  epileptic  attacks 
patients  not  infrequently  complain  of  a  feeling  of  strange- 
ness and  affirm  that  everything  is  far  away.  Although  they 
recognize  that  they  are  in  familiar  surroundings  and  in  the 
presence  of  friends,  they  are  temporarily  devoid  of  the  normal 
feeling  of  recognition.  Bonhoefr" er 40  has  described  similar 
sensations  as  occurring  in  epileptics.  As  the  disturbances  are 
apt  to  be  transitory  in  character,  it  is  impossible  to  make  a 
complete  examination  of  the  psychical  symptoms. 

Somewhat  different  from  the  mere  recognition  of  objects 
or  persons  is  the  power  >  to  re-develop  the  psychic  processes 
associated  with  a  given  stimulus  or  stimuli  after  they  have 
ceased  to  act.  By  this  form  of  memory  we  mean  that  an  indi- 
vidual is  able  to  retain  ideas  or  recognize  objects,  persons,  etc., 
provided  that  a  sufficient  number  of  repetitions  of  the  original 
stimuli  have  taken  place.  The  face  which  seems  strange  to 
us  becomes  familiar  after  being  repeatedly  observed.  But  this 
faculty  frequently  suffers  in  various  forms  of  alienation.  It 
is  important  to  analyze  all  cases  in  which  these  disturbances 
occur  so  as  to  determine,  if  possible,  the  underlying  conditions. 
In  some  instances  the  detention  or  retaining  power  for  new 
impressions  is  impaired.  This  may  be  tested  by  telling  the 
patient  to  remember  three  wTords  and  at  the  end  of  half  a 
minute  asking  him  to  repeat  them,  care  being  taken  that  the 
cortex  is  not  unduly  stimulated  by  allowing  the  patient  to  say 
the  words  aloud.  In  many  forms  of  dementia  the  detention- 
memory  for  even  such  simple  tests  as  this  is  greatly  lowered. 
The  power  to  retain  impressions  may  be  disturbed  by  the  con- 
stant inflow  of  sensory  stimuli,  as  in  the  case  of  delirious 


40  Bonhoeffer,  K. :  Ein  Beitrag  zur  Kenntniss  der  epileptischen  Be- 
wusstseinsstorungen  mit  erhaltener  Erinnerung.  Centralbl.  f.  Nervenheilk., 
1900,  S.  599. 


ANOMALIES    OF    MEMORY  85 

patients  in  whom  a  stimulus  is  not  given  sufficient  time  to  act. 
The  new  impression  is  obliterated  as  soon  as  the  stimulus 
which  has  given  rise  to  it  has  ceased.  The  power  to  receive 
new  impressions  is  seriously  interfered  with  by  various  drugs, 
such  as  the  bromides,  morphin,  etc. 

The  paramnesia,  or  tendency  frequently  shown  by  pa- 
tients to  distort  memory,  is  often  exemplified  in  the  clinic.  In 
hysteria  it  is  no  rare  thing  for  individuals  to  give  the  most 
remarkable  accounts  of  themselves  and  of  their  doings  when 
their  narrative  is  not  based  upon  any  semblance  of  truth. 
These  cases,  as  a  rule,  are  characterized  by  a  marked  increase 
in  the  imaginative  faculty.  Although  the  suggestion  has  been 
made  that  such  a  tendency  to  confabulate  depends  primarily 
upon  isolated  defects  in  associative  memory  of  which  the 
patient  is  only  in  part  conscious,  in  Korsakow's  syndrome,  as 
is  well  known,  individuals  show  a  marked  tendency  to  freely 
indulge  in  pseudo-reminiscences.  As  a  rule,  however,  these 
cases  are  more  easily  recognized  than  are  the  hysterical  liars- 
on  account  of  the  presence  of  more  or  less  impairment  in  all 
the  mental  faculties.  The  tendency  to  lie  and  the  relation  that 
this  bears  to  defective  memory  is  a  theme  of  forensic  bearing. 
Unfortunately,  in  many  cases,  on  account  of  the  present  limita- 
tions in  our  knowledge,  it  is  impossible  to  get  at  the  facts  in 
the  case.  The  hypermnesias  are  frequently  exemplified  not 
only  by  patients  in  the  clinic,  but  are  met  with  in  individuals 
in  every-day  life.  Under  this  head  we  may  group  together 
those  cases  of  phenomenal  memory  in  certain  directions, 
frequently  exhibited  in  the  development  of  certain  talents, 
such  as  the  power  to  calculate  rapidly,  to  learn  by  rote,  or  in 
the  extraordinary  feats  of  memory  exhibited  by  chess  players, 
musicians,  etc.  These  hypermnesias  as  well  as  the  param- 
nesias are  frequently  associated  with  marked  disturbances  in 
the  organic  sensations.  It  is  only  necessary  in  this  connection 
to  refer  to  the  paramnestic  and  hypermnestic  defects  which  fre- 
quently become  marked  in  the  course  of  various  psychoses, 
such  as  manic-depressive  insanity  and  dementia  paralytica. 


86  PSYCHIATRY 

DISTURBANCES    IN    ORIENTATION.41 

By  orientation  is  meant  the  power  of  an  individual  to 
recognize  and  appreciate  his  environment  and  all  that  pertains 
to  it.  This  faculty  is  a  complex  one  and  conditioned  by  a  great 
variety  of  factors,  chief  among  which  is  the  power  of  re-collect- 
ing and  redeveloping  past  impressions.  Disorientation  is  a 
symptom  that  is  frequently  observed  in  cases  of  alienation  and 
by  some  clinicians  is  considered  a  fundamental  anomaly  in 
nearly  all  forms.  In  attempting  to  analyze  the  disturbances  of 
orientation  it  should  not  be  forgotten  that  the  most  elementary 
forms  of  this  process  are  those  directly  associated  with  the 
physiology  of  the  sensory  organs ;  as  we  rise  in  the  animal  scale, 
it  is  found  that  the  primary  sensory  impressions  become  more 
elaborate  and  consequently  more  complex  and  more  difficult  to 
analyze.  Clinical  experience  has  abundantly  shown  that  focal 
lesions  not  infrequently  give  rise  to  disturbances  in  orienta- 
tion. This  is  in  part  due  not  only  to  the  interference  with 
the  transmission  of  afferent  and  efferent  impulses,  but  also 
to  the  more  general  disturbances  dependent  upon  anomalies 
in  the  attention  and  in  associative  memory.  In  cases  in  which 
focal  lesions  have  occurred  the  great  importance  of  the  sen- 
sory tracts  for  the  preservation  of  orientation  at  once  becomes 
apparent.  But  the  disturbances  which  are  of  particular  in- 
terest to  the  alienist  are,  as  a  rule,  those  in  which  such  focal 
lesions  are  not  in  evidence,  although  injuries  to  the  subcortical 
ganglia  may  give  rise  to  a  severe  form  of  disorientation.  In 
the  polyneuritic  psychoses  we  frequently  have  an  excellent  ex- 
ample afforded  of  the  extreme  degrees  of  disorientation  and 
indications  of  the  important  part  probably  played  by  the 
peripheral  tracts  in  the  maintenance  of  normal  relationships 
between  the  individual  and  his  environment.  In  such  instances 
not  only  the  spatial  but  also  the  time  orientation  suffers.  These 
anomalies  are,  as  a  rule,  not  isolated,  but  in  many  instances  are 
complicated  by  considerable  general  impairment  of  all  the  cor- 
tical functions. 

41  Hartmann,  Fritz  :   Die  Orientierung.    Leipzig,  1902. 


ANOMALIES    OF   VOLITION  87 

That  the  preservation  of  the  normal  functions  of  the  cor- 
tex is  essential  to  a  perfect  orientation  is  well  demonstrated 
in  the  early  cases  of  general  paresis.  Paretics  not  infrequently 
seem  utterly  unable  to  interpret  their  spatial  or  time  relation- 
ships correctly.  A  similar  condition  exists  in  many  cases  of 
catatonia,  and  more  than  one  observer  has  attempted  to  show- 
that  the  disorders  of  motility  undoubtedly  play  an  important 
part  in  the  clinical  picture  of  this  disease.  It  is  not  at  all 
improbable,  as  Meynert,  Hartmann,  and  others  have  pointed 
out,  that  the  catatonic  symptom-complex,  which  may  be  char- 
acterized by  practically  no  disturbances  in  sensibility  and  by 
little  interference  with  the  dynamic  power  of  the  muscle,  is 
in  large  part  the  result  of  anomalies  in  the  so-called  muscle 
sense,  and  that  this  latter  disturbance  is  referable  to  inter- 
ference with  the  normal  balance  of  the  cortical  functions. 
Sometimes  in  various  delirious  states  it  is  obvious  that  the 
patient  is  the  subject  of  a  profound  degree  of  disorientation. 
This  may,  in  part,  be  due  to  the  influx  of  fallacious  sense 
perceptions,  which  create,  as  it  were,  a  temporary  imaginary 
world  in  which  the  individual  lives  and  to  which  he  tries  to 
adjust  himself.  Disturbances  of  this  character  are  not  un- 
common in  delirium  tremens,  amentia,  and  a  number  of  other 
conditions.  Another  form  of  the  disorder  is  noted  in  states 
of  depression,  to  a  certain  extent  because  incoming  stimuli 
fail  to  be  elaborated  and  only  serve  to  direct  more  forcibly  the 
patient's  attention  to  his  own  symptoms.  Sometimes  in  the 
manic  stupor  individuals  seem  to  completely  fail  to  appreciate 
their  surroundings  and  have  a  deficient  time  sense.  In  all 
forms  of  apathy  there  is  a  considerable  degree  of  disorien- 
tation which  is  also  to  be  attributed  to  the  disturbances  in 
associative  memory  and  the  inability  of  the  individual  to  re- 
collect past  impressions  and  to  compare  them  with  sufficient 
accuracy  with  other  experiences. 

VI.  DISTURBANCES  IN  THE  VOLITIONAL  PROCESSES. 

Among  the  more  complicated  of  the  psychic  processes  are 
those  which  are  commonly  grouped  under  the  head  of  voli- 


88  PSYCHIATRY 

tion.  This  series  of  phenomena  belongs  to  the  more  highly- 
organized  functions  of  the  brain.  Anomalies  of  volition  in 
the  insane  are  not  essentially  different  from  those  found  in 
the  individual  who  is  not  the  subject  of  mental  aberration, 
although  the  popular  belief  among  the  laity  commonly  assumes 
that  the  disturbances  of  will  which  occur  during  the  course 
of  alienation  are  the  result  of  certain  conditions  and  modi- 
fications which  do  not  enter  into  the  general  discussion  of 
the  so-called  problem  of  the  will.  Science  affirms  that  all 
our  acts  are  the  correlates  of  the  associated  brain  processes 
and  that  the  phenomena  of  volition  are  primarily  conditioned 
by  sensation  and  by  variously  elaborated  and  complex  memory- 
pictures,  and  not  by  the  interposition  of  some  new  form  of 
psychical  activity.  The  will  as  a  specific  function  does  not 
exist.  The  acts  of  the  individual,  whether  sane  or  insane,  are 
only  the  consequences  of  physical  conditions  which,  if  they 
were  fully  understood,  would  render  it  possible  to  foretell 
the  character  of  the  act.  In  other  words,  the  power  of  voli- 
tion possessed  by  any  given  individual  is  in  direct  proportion 
to  the  functional  capacity  of  his  brain,  and  to  assume  that 
he  is  endowed  with  some  psychic  power  superior  to  the  poten- 
tial efficiency  of  the  central  nervous  system  is  an  hypothesis 
that  has  no  justification  in  facts. 

The  neural  elements  in  the  cerebral  cortex  are  not  only- 
responsible  for  the  reception,  retention,  and  modification  of 
sensory  stimuli,  but  also  have  to  do  with  the  initiation  and  con- 
ditioning of  the  efferent  impulses.  These  impulses  determine 
the  acts  or  the  conduct  of  the  individual,  and  between  incident 
motion  or  the  stimulus,  on  the  one  hand,  and  the  motor  re- 
sponse, on  the  other,  is  interposed  a  series  of  phenomena  which 
depend  upon  the  structure  and  functional  capacity  of  the  cen- 
tral nervous  system.  The  brain  determines  the  kind  of  re- 
sponse and  gives  to  a  series  of  muscular  movements  a  definite 
stamp  and  character.  Thus,  for  example,  we  recognize  an 
individual  by  his  walk  or  by  the  character  of  his  facial  ex- 
pression ;  in  other  words,  we  have  in  a  general  way  a  definite 
picture  of  the  manner  in  which  muscles  under  certain  condi- 


ANOMALIES    OF   VOLITION  89 

tions  respond  to  certain  given  stimuli,  and  these  motor  reac- 
tions, as  has  already  been  said,  are  determined  by  the  central 
nervous  system. 

In  order  to  obviate  the  difficulty  of  describing  the  voli- 
tional processes  in  terms  that,  unfortunately,  have  a  metaphysi- 
cal meaning,  and  thus  set  up  new  stumbling-blocks  that  serve 
to  thwart  the  efforts  of  the  investigator  in  his  attempted  solu- 
tion of  these  and  similar  problems,  some  physiologists  (Bethe, 
Beer,  and  Uexhill)  have  proposed  that  only  such  terms  shall 
be  employed  as  shall  serve  to  indicate  the  immediate  depend- 
ence of  the  volitional  no  less  than  the  reflex  movement  upon 
the  functional  capacity  of  the  central  nervous  system.  With 
this  end  in  view  Bethe  has  suggested  that  all  forms  of  nervous 
response  should  be  designated  as  antikineses,  while  those  re- 
curring regularly  and  in  a  definite  manner  in  response  to 
stimulation  shall  be  called  reflexes,  whereas  all  the  volitional 
responses  in  which  there  is  a  variable  factor  due  to  the  greater 
complexity  and  elaboration  in  the  physiological  mechanism 
shall  be  classed  together  as  antiklises.*2  The  acts  of  an  indi- 
vidual under  normal  conditions  vary  within  comparatively 
narrow  limits;  the  limitations  are  imposed  by  the  functional 
capacity  of  the  higher  brain-centres.  Coordination  and  con- 
tinuity of  movement  as  well  as  of  thought  depend  upon  the 
integrity  of  the  neural  elements  in  the  higher  brain-centres. 

There  is  a  remarkable  degree  of  uniformity  in  the  mech- 
anism of  all  forms  of  movement.  The  general  laws  which  hold 
good  for  the  simplest  are  applicable  with  certain  modifications 
to  those  of  greater  complexity.  Reflex  movements  may  be 
defined  as  those  following  immediately  upon  the  incidence  of 
a  stimulus  without  the  interposition  of  any  cerebral  process 
of  which  we  are  conscious.  This  form  of  movement  may  be 
intensified  or  inhibited  as  the  direct  result  of  sensory  stimula- 
tion. The  same  is  true  of  movements  in  which  there  at  one 
time  has  been  an  element  of  consciousness  but  which,  through 


12  Bethe,    A. :    Allegemeine    Anatomie    und    Physiologie    des    Nerven- 
systems.    Leipzig,  1903. 


90  PSYCHIATRY 

constant  repetition,  have  become  reflex  or  automatic.  In  the 
normal  individual  the  eyelids  are  quickly  closed  in  response  to 
visual  stimuli,  and  protection  is  thus  given  to  the  eyeballs  from 
injury  from  without.  If,  however,  the  cerebral  processes  are 
inhibited  by  disease  so  that  the  reflex  closure  of  the  lids  is 
impossible,  no  response  follows  the  stimulus.  Volitional 
movements  differ  from  reflex  and  automatic  acts  in  the  fact 
that  prior  to  the  discharge  of  the  efferent  impulse  an  idea  of 
the  movement  to  be  executed  appears  in  consciousness,  and, 
as  will  be  seen  later,  it  is  upon  this  phenomenon  that  the  idea 
of  freedom  in  choice  in  all  volitional  acts  depends/ 

Expressed  in  physiological  terms,  a  volitional  process  may 
be  said  to  consist  in  the  reception  of  the  stimulus,  its  retention 
and  elaboration,  brought  about  by  the  activity  of  the  higher 
brain-centres,  and  finally  the  motor  discharge.  The  complexity 
of  the  processes  concerned  in  the  act  depends  primarily  upon 
the  response  of  the  neural  elements  to  the  primary  stimula- 
tion. As  has  frequently  been  pointed  out,  the  volitional  proc- 
esses, from  a  scientific  stand-point,  may  be  considered  to 
represent  the  totality  of  those  conditions  of  which  we  are  in 
part  conscious  and  that  are  directly  related  to  a  series  of 
movements  and  to  whatever  is  contingent  upon  their  execu- 
tion (Mach).  The  conditions  to  which  an  individual  is  sub- 
jected may  produce  disturbances  of  sensation  or  of  memory, 
and  may  also  give  rise  to  anomalies  of  volition.  This  is 
equivalent  to  saying  that  just  as  there  may  be  delay  or  resist- 
ance in  the  reception,  storing,  and  elaboration  of  stimuli,  so 
there  may  be  opposition  in  the  course  of  their  emission.  (See 
tics,  stereotyped  movements,  negativism.)  The  psychomotor 
retardation  in  cases  of  depression  and  the  psychomotor  excita- 
bility in  maniacal  patients  afford  respectively  good  examples 
of  the  difficulty  and  of  the  ease  with  which  volitional  acts  may 
be  executed.  In  the  former  case  all  forms  of  movement  are 
difficult,  so  that  not  only  is  there  a  delay  in  the  reception  and 
actual  association  of  the  afferent,  but  the  discharge  of  the 
efferent  impulse  is  impeded.  In  states  of  mania,  however,  the 
opposite  conditions  prevail,  and  the  execution  of  many  voli- 


ANOMALIES    OF   VOLITION 


91 


tional  acts  is  carried  out  with  greater  ease  and  rapidity  than 
is  normally  the  case. 

Those  who  are  familiar  even  with  the  elementary  facts 
of  physiology  realize  that  sensations  and  memory-pictures  are 
indissolubly  connected;  there  is  no  sharp  line  dividing  them. 
Disturbances  in  the  functions  we  call  memory  may  produce 
anomalies  in  sensation,  and  vice  versa.  There  is  an  intimate 
dependence  of  the  one  series  of  phenomena  upon  the  other  and, 
therefore,  impairment  of  one  set  of  functions  reacts  upon  the 
others.  What  is  true  in  regard  to  sensation  and  memory  is 
equally  true  in  regard  to  the  greater  complexity  of  functions 
we  call  the  will.  Loss  of  vision  impairs  the  volitional  power 
associated  with  certain  movements ;  for  example,  the  blind  man 
stands  irresolute  owing  to  the  impairment  of  those  acquired 
reactions  which,  in  a  measure,  are  conditioned  by  vision.  The 
impairment  of  volition  may  be  the  result  of  diminished  func- 
tion of  the  sense  organs  or,  as  in  various  psychoses,  is  caused 
by  the  limitation  and  inhibition  of  the  cortical  functions.  The 
individual  differences  in  the  effect  of  a  given  stimulus  is  a 
matter  of  everyday  experience.  One  person  may  look  over 
the  edge  of  a  precipice  without  feeling  a  strong  and  almost  irre- 
sistible force,  the  consequence  of  certain  organic  sensations, 
impelling  him  to  throw  himself  headlong  into  the  abyss  below, 
while  another  experiences  this  impulse.  The  differences  in 
the  individual  reactions  and  the  degree  of  impairment  of  voli- 
tion following  the  use  of  alcohol,  tobacco,  cocain,  and  other 
drugs  are  well  known.  Under  certain  conditions  stimuli 
awaken  in  one  individual  a  chain  of  impulses  and  desires  that 
in  another  person  are  either  entirely  absent  or  so  feeble  as 
not  to  require  any  special  act  of  will  to  overcome  them.  In 
the  functions  of  the  nervous  system  are  to  be  found  the  main- 
spring of  those  desires  that  serve  to  attract  or  repel  us  from 
certain  objects,  and  that  render  one  situation  or  event  pleasant 
and  another  painful.  As  the  new  needs  spring  into  being,  the 
organism  reacts  in  a  manner  determined  by  established  trends 
and  inclinations  that  are  partly  the  result  of  congenital  and 
partly  of  the  acquired  functions  of  the  central  nervous  system. 


92  PSYCHIATRY 

We  inherit  a  brain  endowed  with  certain  capacities  that  may- 
be increased  by  education  and  the  stimulating  effects  of  our 
environment.  The  difference  in  the  volitional  acts  of  two  indi- 
viduals is  primarily  determined  by  the  disparity  in  the  func- 
tions of  their  nervous  systems.  One  individual  is  bright,  re- 
sponsive, and  emotional;  the  other  is  dull  and  phlegmatic.  In 
the  former  the  reception  and  elaboration  of  incident  stimuli 
are  followed  by  a  prompt  and  quick  discharge  of  efferent 
impulses,  while  in  the  latter  the  opposite  condition  prevails. 

The  alienist  is  interested  in  disturbances  of  volition  from 
two  stand-points.  In  the  first  place,  he  considers  these  abnor- 
mal phenomena  from  a  clinical  point  of  view,  and,  in  the 
second,  they  have  an  important  forensic  bearing.  The  acts 
of  an  individual  who  is  the  subject  of  alienation  may  deviate 
from  the  normal  as  a  result  of  a  number  of  conditions.  For 
this  reason  it  is  impossible  to  judge  of  the  disturbances  in  the 
volitional  processes  without  a  careful  study  of  the  individual 
case.  When  there  is  a  considerable  impairment  of  all  the 
intellectual  processes,  as  a  result  of  this  functional  defect,  the 
individual  may  show  marked  impairment  in  his  voluntary  acts. 
Such  is  the  case  in  idiocy,  imbecility,  and  various  forms  of 
dementia.  On  the  other  hand,  the  presence  of  hallucinations 
or  illusions  may  condition  the  conduct.  The  crucial  point  in 
passing  judgment  regarding  the  acts  of  a  patient  rests  upon 
the  decision  as  to  whether  the  individual  who  was  the  sub- 
ject of  hallucinations  or  illusions  recognized  these  phenomena 
as  abnormal,  and  whether  they  were  in  any  sense  a  factor  of 
importance  in  conditioning  his  act.  The  conduct  of  an  indi- 
vidual is  not  infrequently  determined  by  the  existence  of  an 
emotional  state,  and  emotional  excitement  is  primarily  due  to 
functional  changes  in  the  central  nervous  system.  Among  the 
cases  where  the  disturbances  of  volition  are  of  great  moment 
are  those  in  which  impulses  dominate  the  acts  of  the  patient. 
These  impulses  are  of  great  variety  and  of  varying  degrees 
of  intensity.  (See  Obsessions.)  In  all  disturbances  of  con- 
sciousness, so  common  in  various  psychoses,  there  is  necessa- 
rily some  impairment  of  the  volition.     In  various  forms  of 


ANOMALIES    OF   VOLITION  93 

alienation  the  clinician  is  struck  by  the  fact  that  in  some  cases 
the  voluntary  acts  of  an  individual  seem  to  be  confronted  with 
a  certain  amount  of  opposition ;  while  in  other  cases  the  resist- 
ance interposed  between  the  psychical  event,  on  the  one  hand, 
and  the  physical  reaction,  upon  the  other,  is  below  the  normal, 
and  the  patient  seems  to  act  with  greater  promptitude  than 
under  ordinary  conditions.  As  an  instance  of  the  former  class 
may  be  cited  the  psychomotor  retardation  noticeable  in  the 
periods  of  mental  depression,  and  of  the  latter  the  increased 
excitability  so  common  in  states  of  mania  as  well  as  in  the 
early  stages  of  alcoholism.  In  conditions  of  fatigue  there  is 
also  a  marked  diminution  in  the  intensity  and  duration  of  the 
so-called  voluntary  acts.  The  same  is  true  in  the  various 
forms  of  dementia. 

The  ghost  of  metaphysical  speculation  continuously  con- 
fronts the  alienist  when  he  attempts  to  deal  with  volitional 
processes  in  which  there  is  an  apparent  choice  between  one 
or  more  motives.  The  doctrine  of  the  so-called  freedom  of 
the  will  is  one  that  has  long  been  jealously  guarded  from 
assault  by  the  theologian  and  metaphysician.  There  are  cer- 
tain obvious  factors  in  connection  with  this  discussion  that 
clearly  show  the  problem  to  be  one  whose  attempted  solution 
lies  within  the  province  of  the  alienist.  It  is  a  matter  of  com- 
mon clinical  experience  that  the  sense  of  freedom  associated 
with  volitional  acts  in  the  normal  individual  may  be  present 
with  even  greater  force  in  the  consciousness  of  the  patient 
who  is  the  subject  of  alienation.  The  consciousness  of  free- 
dom accompanying  all  volitional  acts  is  the  result  of  certain 
cortical  functions.  As  has  been  indicated,  the  intensity  of 
this  sense  of  freedom  varies  not  only  in  different  individuals, 
but  at  different  times  in  the  same  person.  The  feeling  may 
be  greatly  diminished  in  states  of  mental  depression  as  well 
as  in  fatigue  or  after  the  administration  of  morphin  and  the 
bromides.  This  condition  is  in  marked  contrast  with  the  ex- 
travagant sense  of  freedom  common  in  cases  of  paresis  or 
alcoholism  and  so  frequently  described  in  language  that  by 
its  exaggerated  character  indicates  the  remarkable  changes  in 


94  PSYCHIATRY 

the  organic  sensations  upon  which  the  feeling  is  based.  The 
consciousness  of  freedom  that  accompanies  nearly  all  volitional 
acts  is  a  composite  of  sensations,  emotional  reactions,  and 
ideas.  The  prominence  of  the  ideational  element,  dependent 
as  it  is  on  the  occurrence  of  certain  organic  sensations,  is 
greater  in  those  instances  where,  subsequent  to  the  perform- 
ance of  an  act,  there  is  the  feeling  that  another  motive  or 
line  of  action  than  the  one  chosen  might  have  been  selected. 
The  consciousness  of  freedom  is  referable  not  only  to  the  act, 
but  also  to  the  accompanying  desire  or  wish.  As  has  already 
been  pointed  out,  somatic  disturbances  that  affect  the  per- 
sonality or  somato-psychic  field  of  consciousness  are  charac- 
terized by  disorders  of  the  volitional  processes.  The  ego,  or 
idea  of  personality,  represents  an  indefinite  and  variable  group 
of  organic  sensations.  We  are  not  the  same  to-day  that  we 
were  a  year  ago.  When  weakened  by  disease,  exhausted  by 
fatigue  or  hunger,  the  limitations  in  our  psychic  personality 
and  volitional  processes  are  to  some  extent  proportional  to 
each  other.  It  is  important  to  bear  in  mind  the  fact  that  the 
sense  of  freedom  supposed  to  accompany  a  decision  as  to  the 
choice  of  motive  does  not  occur  at  the  instant  the  choice  is 
made,  but  is,  in  fact,  a  subsequent  development.  As  Hoche  43 
has  affirmed,  we  are  unable  to  observe  and  record  exactly  all 
the  processes  that  occur  at  the  moment  a  choice  is  made.  The 
attempt  to  do  this  necessitates  a  recollection  and  redevelop- 
ment on  our  part  of  all  that  has  actually  happened.  The  sense 
of  freedom  is  in  reality  an  after-thought.  The  duty  of  the 
alienist  is  to  determine  in  individual  cases  the  different  con- 
ditions that  influence  the  thought  and  conduct  of  individuals. 
Frequently  it  is  impossible  to  ascertain  and  analyze  the 
facts,  but  we  only  increase  and  do  not  diminish  our  ignorance 
by  substituting  for  the  supposed  conditions  an  unvarying  and 
indescribable  psychic  force  by  and  through  which  mountains 
are  supposed  to  be  moved. 


42  Die  Freiheit  des   Willens  vom   Standpunkte  der   Psychopathologie. 
Wiesbaden,  1902. 


ANOMALIES    OF   VOLITION 


95 


Tics  not  infrequently  occur  during  the  course  of  the  psy- 
choses and  seriously  interfere  with  the  prompt  execution  of  sim- 
ple volitional  movements.  In  certain  disorders,  more  particularly 
in  dementia  prsecox,  imbecility,  and  idiocy,  both  tonic  or  clonic 
convulsive  movements  are  common.  These  motor  disturb- 
ances may  be  secondary  and  connected  with  the  appearance  of 
hallucinations,  delusions,  insane  ideas,  or  imperative  concep- 
tions. The  disturbance  is  of  psychomotor  origin;  that  is, 
there  are  two  elements  which  are  of  etiological  importance — 
the  mental  and  the  motor.  The  relative  importance  of  these 
two  factors  varies  in  different  cases.  The  impairment  of  the 
volitional  power  is  dependent  upon  the  insufficiency  and  ir- 
regularity of  the  cortical  functions.  These  phenomena  seem 
to  indicate  the  incomplete  development  of  certain  psychic 
functions,  and  the  anomalies  of  volition  which  accompany  va- 
rious forms  of  tic  are  the  result  of  a  mental  disequilibration. 
In  some  cases  the  movements  primarily  represent  responses 
to  external  stimuli ;  later,  the  stimuli  having  ceased  to  act,  the 
originally  peripherally  incited  movement  becomes  automatic. 
In  other  cases  the  movements  may  be  the  result  of  an  insane 
idea. 

Various  forms  of  tic  are  met  with  associated  with  aliena- 
tion. These  sudden,  incoordinated,  and  involuntary  move- 
ments may  be  accompanied  by  considerable  psychical  disturb- 
ances, as  in  Huntington's  chorea.  According  to  Charcot,44 
"tic  is  a  disease  which  is  not  material  except  in  its  appear- 
ance;" in  other  words,  the  affection  is  in  reality  "  a  psychical 
disease,  a  direct  product  of  vesania."  Brissaud  has  also  called 
attention  to  the  abnormal  mental  state  in  patients  afflicted  with 
tic.  Meige  and  Feindel  45  have  also  emphasized  the  impor- 
tance of  the  manifestations  of  motor  storms  with  the  asso- 
ciated mental  aberration.  It  is  impossible  at  present  to  refer 
in  detail  to  the  various  manifestations  of  tic;  the  mental  dis- 
turbances associated  with  them  are  described  elsewhere. 


Legons  du  Mardi,  1887-88,  p.  124. 

Les  Tics  et  leur  Traitement.    Paris,  1902,  p.  136. 


96  PSYCHIATRY 

Stereotyped  Movements. — Contrasted  with  these  eccen- 
tricities of  movements  is  another  class  of  motor  disturbances — 
stereotyped  movements — which  play  an  important  part  in  the 
symptomatology  of  a  large  group  of  cases.  The  phenomena 
belonging  to  these  are  of  various  kinds  and  may  be  collectively 
classified  as  stereotypies  of  movement  or  of  attitude.  The 
former  are  sometimes  spoken  of  as  primary,  the  latter  as  sec- 
ondary.46 Not  infrequently  the  former  are  limited  to  the 
facial  muscles.  The  patient  screws  up  one  corner  of  the 
mouth,  closes  one  or  both  eyes,  puckers  up  his  lips  to  form  the 
curious  "  snouting  cramp"  so  frequently  observed.  At  times 
these  disturbances  are  limited  to  speech.  There  may  be  a 
stereotyped  tone  of  voice  or  character  of  the  inflexion.  In- 
articulate sounds,  words,  or  phrases  are  repeated  (stereotyped 
embolophrasia).  Coprolalia  may  occur,  but  is  more  frequently 
associated  with  some  form  of  tic.  Automatism  is  frequently 
noted.  The  patient  is  told  to  protrude  his  tongue,  and  the 
alternate  protrusion  and  retraction  is  continued  until  he  is  told 
to  stop.  When  a  reason  for  this  continuation  is  asked  for.  a 
senseless  answer  is  given  or  the  patient  becomes  evidently 
embarrassed  in  attempting  to  find  an  explanation. 

Stereotyped  movements  not  infrequently  resemble  tics. 
In  character  the  muscular  contractions  do  not  differ  essen- 
tially from  those  of  normal  actions,  but  as  the  result  of  habit 
have  become  involuntary.  Stereotypies  are  never  convulsive. 
In  clonic  tic  the  rapidity  of  the  muscular  contraction  is  exag- 
gerated, while  in  the  tonic  cases  the  duration  is  prolonged. 
The  basis  of  many  stereotyped  movements  is  to  be  found  in 
the  acts  of  every-day  life.  The  individual  is  characterized 
by  his  attitude,  by  his  manner  of  walking,  by  the  personality 
exhibited  in  his  gestures,  etc.  These  may  become  accentuated 
during  an  attack  of  alienation.  Cahen  47  pointed  out  that  the 
stereotypies  of  attitude  or  movement  are  coordinated  and  are 


46  Ziehen  :    Psychiatrie,  2te  Auflage,  1902. 

47  Contribution   a   l'etude   des   stereotypies.     Arch,    de   Neurol.,    Dec, 
1901,  p.  474- 


ANOMALIES    OF   VOLITION 


97 


not  in  any  sense  involuntary,  but  have  the  appearance  of  being- 
carried  out  for  a  purpose,  at  first  conscious  and  voluntary, 
but  becoming  through  constant  repetition  automatic. 

The  incidence  of  stereotyped  movements  in  insane  pa- 
tients is  in  most  instances  in  all  probability  primarily  due  to 
an  insane  idea.  Later  the  idea  disappears,  but  the  movements 
persist.  It  is  sometimes  difficult  to  distinguish  between  the 
purely  impulsive  acts  of  the  person  who  is  the  subject  of  a 
tic  and  those  stereotyped  movements  which  not  infrequently 
are  characterized  by  a  brusque  explosiveness  suggesting  the 
former  rather  than  the  latter  type  of  movements.  The  stereo- 
typies of  attitude  may  be  designated  as  akinetic,  while  those 
of  movement  are  parakinetic  disturbances.  The  latter  are  very 
numerous,  affecting  various  movements,  the  muscles  concerned 
in  speech,  gesture,  mimicry,  and  not  infrequently  the  writing. 
The  psychic  correlate  is  shown  in  the  expression  of  ideas. 

The  frequency  with  which  these  stereotypies  are  associ- 
ated with  insane  ideas  referring  to  movements  of  defence  sug- 
gested to  Bressler  that  this  symptom-complex  was  a  neurosis 
of  self-protection  due  to  an  exaggerated  excitability  of  the 
psychomotor  centres.  He  proposed  the  name  "  mimic-cramp 
neurosis,"  basing  his  theory  on  the  observations  of  Brenner 
and  Freud  in  cases  of  hysteria  where  the  movements  were 
thought  to  be  largely  imitative. 

Negativism. — Another  condition  not  at  all  infrequent  in 
certain  forms  of  alienation,  particularly  in  catatonia,  is  the 
so-called  negativism.  This  may  occasionally  be  mistaken  for 
psychomotor  retardation,  and  is  associated  with  considerable 
impairment  of  the  volitional  processes.  When  negativism  is 
well  marked  there  is  resistance  to  all  passive  movements.  Fre- 
quently the  patient  does  not  wait  to  be  touched,  but  turns  away 
his  head,  closes  his  eyes,  runs  into  a  far  corner  of  the  room, 
crawls  under  the  bed,  any  stimulus  immediately  arousing 
marked  antagonism.  At  times  associated  with  this  is  the 
characteristic  catatonic  rigidity  of  the  muscles,  but  the  two  con- 
ditions are  not  often  found  to  exist  synchronously.  The  nega- 
tivism may  be  extreme  or  only  transitory  and  of  a  mild  degree 

7 


q8  psychiatry 

of  intensity.  The  refusal  to  eat  may  be  a  marked  feature  in 
such  cases,  and  the  urine  and  faeces  may  not  be  voided  for  long 
periods  of  time.  The  attitude  of  the  patient  is  silly  and  appa- 
rently purposeless.  In  an  aggressive  or  irritable  patient  an 
hallucination  or  delusion  will  generally  be  found  to  be  the 
guiding  motive  of  his  conduct.  Gross48  explains  one  form 
of  negativism  as  in  part  the  result  of  psychomotor  or  intra- 
psychic inhibition.  A  psychohypsesthesia  limits  or  inhibits  the 
patient  in  his  response  to  various  stimuli,  and  be  becomes  con- 
scious of  the  fact  that  he  is  not  in  harmony  with  his  environ- 
ment. Such  a  state  is  observable  in  the  confusion  which  occurs 
in  senile  psychoses  where  the  symptoms  are  directly  depend- 
ent upon  the  limitation  in  sense  perception.  In  another  group 
of  cases  the  patient  is  ill  at  ease,  dislikes  interference,  gives 
evidence  of  his  emotional  state  in  his  facial  expression,  takes 
little  interest  in  his  surroundings.  The  more  marked  catatonic 
symptoms  are,  as  a  rule,  absent,  but  the  patient  is  suspicious  of 
those  about  him.  When  questioned  or  approached  he  shows 
plainly  his  disinclination  to  be  interfered  with,  complains  of 
being  disturbed,  or  may  even  become  aggressive  and  energeti- 
cally active.  In  this  group  of  cases  there  is  evidently  an  insane 
idea  as  well  as  the  consciousness  of  the  inability  to  respond 
promptly  to  external  stimuli.  This  latter  physical  defect  is 
the  basis  of  an  emotional  depression.  The  patient  realizes  that 
he  is  unable  to  receive  and  elaborate  stimuli  which  come  to 
him.  The  persistence  of  these  disturbing  factors  may  give 
rise  to  marked  anxiety  which  may  exaggerate  the  psychic 
defect. 

The  immediate  cause  of  these  phenomena  cannot  be  re- 
ferred solely  to  the  lowering  of  the  volitional  impulses.  Krae- 
pelin  and  Sommer  believe  that  the  various  catatonic  disturb- 
ances, such  as  negativism,  echolalia,  echopraxia,  stereotypy, 
mannerisms,  and  impulses  all  have  a  common  foundation. 
Two  factors  are  intimately  associated  with  their  occurrence. 

48  Die  Affektlage  der  Ablehnung.     Monatsschr.   f.   Psych,  u.   Neurol., 
Bd.  xii,  Oct.,  1902,  H.  4,  S.  359. 


ANOMALIES    OF   VOLITION 


99 


There  is  either  a  stereotypy  shown  by  the  increased  tendency 
of  some  movement  or  series  of  movements  to  recur  after  the 
incidence  of  the  initial  stimulus,  or  the  element  of  suggesti- 
bility is  nearly  always  present.  Vogt,49  however,  does  not 
believe  that  it  is  possible  to  explain  the  symptoms  in  detail 
upon  such  a  foundation.  Basing  his  opinion  upon  the  work 
of  Miiller  and  Pilzecker,50  as  well  as  upon  that  of  James,  he 
is  inclined  to  believe  that  a  representation  appears  in  the  field 
of  consciousness  prior  to  every  act  or  movement,  and  remains 
there  until  displaced  by  an  opposing  reproduction.  If  the 
latter  is  absent,  the  movement  as  executed  does  not  involve  the 
so-called  volitional  processes.  If  more  than  one  representation 
is  present  in  the  field  of  consciousness,  it  becomes  necessary 
to  choose,  and  the  selection  represents  a  voluntary  choice. 
When  there  is  no  abnormal  psychomotor  irritation,  movements 
resulting  from  choice  not  connected  with  great  effort  are  made 
half  involuntarily.  The  result  is  different  when  there  are 
concurring  impulses  and  centres  whose  instability  is  subnormal. 
An  additional  force  is  then  necessary  to  focus  the  attention 
upon  the  idea  of  movement.  This  may  awaken  a  subjective 
feeling  of  resistance  that  must  be  overcome.  Associated  with 
this  there  is  a  tendency  of  processes  once  initiated  to  persevere 
in  face  of  the  increased  opposition;  but  working  against  this 
increased  perseverance  or  perseveration  of  the  process  there 
are  a  limiting  and  inhibition  of  the  various  associational  ac- 
tivities of  the  brain.  As  a  result,  the  idea  of  movement  or 
position,  once  in  the  field  of  consciousness,  persists  there  until 
it  is  forcibly  dislodged.  A  patient  in  a  cataleptic  state  will 
frequently  hold  his  arm  in  an  uncomfortable  position  even 
when  pricked  with  a  pin  or  pinched  or  when  another  limb  is 
put  in  an  equally  uncomfortable  position.  But  if  he  is  asked 
to  execute  a  voluntary  movement  and  is  capable  of  responding, 
as  the  new  idea  associated  with  changed  position  or  with  a 


49  Centralb.  f .  Nervenheilk.  u.  Psych.,  Juli,  1902,  vol.  xix. 
80  Experiment.  Beitrage  zur  Lehre  von  Gedachtniss.    Ztschr.  f.  Psych., 
1900,  Supplement,  Band  i. 


IOO  PSYCHIATRY 

voluntary  act  rises  above  the  threshold  of  consciousness,  the 
old  idea  is  dislodged  and  the  arm  first  elevated  slowly  drops. 
It  is  claimed  by  some  that  a  condition  akin  to  this  is  common 
after  severe  mental  or  physical  fatigue.  It  is  not  definitely 
proven,  however,  that  all  cases  are  capable  of  being  explained 
on  the  same  basis.  Patients  sometimes  assume  attitudes  or 
give  expression  to  stereotyped  forms  of  speech  as  the  result  of 
a  delusion.  These  catatonic  symptoms  may  be  initiated  as  the 
result  of  delusions,  but  may  eventually  become  more  or  less 
automatic. 

Imperative  Processes.51 — A  train  of  thought  may  be  dis- 
turbed or  even  completely  inhibited  by  the  sudden  spontaneous 
appearance  in  consciousness  of  ideas  which  are  recognized  by 
an  individual  as  irrelevant  and  unreasonable.  The  occurrence 
of  these  ideas  may  be  merely  temporary  or  they  may  persist 
for  so  long  a  time  as  to  harass  and  even  terrify  the  person. 
One  of  their  distinguishing  characteristics  is  the  inability  of 
the  individual  to  banish  them  from  consciousness.  These  phe- 
nomena have  received  various  names — obsessions,  imperative 
ideas,  perceptions,  conceptions,  or  reproductions. 

Closely  allied  to  the  imperative  ideas  is  another  group  of 
phenomena  in  which  the  compulsion  to  perform  certain  acts 
seems  to  be  the  essential  factor  in  their  pathogenesis.  Recently 
Bianchi 52  has  suggested  the  possibility  of  roughly  grouping 
these  phenomena  into  (i)  obsessional  emotions,  (2)  obses- 
sional ideas,  and  (3)  obsessional  impulses. 

Westphal's  53  description  of  these  processes  was  the  one 
which  for  a  long  time  was  generally  accepted  by  alienists. 
This  author  called  attention  to  the  fact  that  at  least  four  fac- 
tors were  characteristic  of  them : 

( 1 )  The  normal  intelligence ; 

(2)  Absence  of  any  primary  emotional  disturbance; 

(3)  The  imperative  manner  in  which  they  force  them- 
selves into  the  foreground  of  consciousness ; 

61  Loewenfeld,    L. :     Die    psychischen    Zwangsercheinungen.      Wiesba- 
den, 1904. 

62  Clinica  Moderna,  1899. 
53  Arch.  f.  Psych.,  Bd.  ii. 


ANOMALIES    OF   VOLITION  IOI 

(4)  Their  recognition  by  the  patient  as  foreign  and  ab- 
normal. 

In  1869  von  Krafft-Ebing  pointed  out  the  frequency  with 
which  obsessions  occur  in  certain  forms  of  alienation.  In  fact, 
the  relative  importance  of  these  phenomena  was  considered  to 
be  so  great  that  certain  psychoses  in  which  they  seemed  to  be 
the  chief  symptom  were  grouped  together  under  the  head  of 
the  imperative-process  psychoses  (die  Zwangsvorstellungen- 
psychosen).  Various  conditions,  such  as  fatigue,  hunger,  pro- 
longed mental  or  physical  exertion,  seem  to  favor  the  develop- 
ment of  these  phenomena. 

Friedmann 54  has  recently  called  attention  to  the  fact  that 
the  genetic  conditions  which  give  rise  to  these  dominating 
conceptions  are  not  well  understood,  and  consequently  any 
attempt  to  adjust  our  present  knowledge  regarding  them  so 
as  to  satisfy  a  purely  clinical  conception  may  lead  to  confusion. 
The  difficulty  of  differentiating  obsessions  from  various  other 
phenomena  which  are  associated  with  marked  emotional  dis- 
turbances is  often  very  great.  The  same  is  true  in  regard  to 
the  difficulty  of  distinguishing  the  imperative  conceptions 
which  frequently  occur  during  the  course  of  various  psychoses 
from  the  fixed  ideas  which  often  interfere  with  and  domi- 
nate the  reasoning  powers  of  a  patient.  In  order  to  facilitate 
the  differentiation  of  these  phenomena  Friedmann  has  endeav- 
ored to  explain  the  occurrence  of  the  imperative  idea  on  a 
different  basis  from  the  one  given  by  Westphal.  The  latter's 
explanation  may  account  for  the  simpler,  compulsory  repro- 
ductions, but  this  definition  is  inapplicable  to  the  imperative 
ideas,  impulses,  or  the  imperative  thinking  so  frequently  ob- 
served in  cases  where  the  whole  emotional  and  intellectual  life 
of  the  patient  is  dominated  by  the  obsession.  Westphal's  defi- 
nition simply  refers  to  the  manner  which  characterizes  the 
appearance  of  the  perception  in  consciousness.  It  takes  no 
account  of  the  fact  that  the  actual  content  of  the  reproduction 
may  be  a  factor  of  considerable  importance.     Unquestionably 

M  Centralb.  f.  Nervenheilk.  u.  Psych.,  Nr.  144,  1902. 


102  PSYCHIATRY 

in  some  cases  the  enthralling  power  of  the  obsession  may  be 
due  to  the  fact  that  the  appearance  in  consciousness  is  so  sud- 
den and  so  distressing  that  all  other  psychical  processes  are 
inhibited.  In  other  cases  the  agency  of  chance  external  stimuli 
may  be  admitted  as  an  etiological  factor.  In  these  latter  cases 
an  obsession  takes  the  form  of  an  echo-like  reproduction,  as 
in  echolalia.  In  conditions  of  fatigue  or  exhaustion  patients 
frequently  complain  of  the  constant  and  annoying  recurrence 
of  certain  tunes,  melodies,  phrases,  verses  of  poetry,  etc.,  which 
they  have  heard.  The  more  aggravated  forms,  on  account  of 
their  sudden  startling  appearance  in  consciousness,  are  in  many 
ways  analogous  to  muscular  cramps.  Certain  authorities  have 
spoken  of  them  as  "  reproduction"  or  "  memory  cramps." 
Ribot  has  referred  to  them  as  characterized  by  a  semi-tetanized 
attention  (Aufmerksamkeit).  As  already  stated,  the  forms 
which  may  be  included  under  this  head  are  comparatively  few. 
Another  factor  is  prominent  in  their  pathogenesis.  The  simple 
memory  of  a  past  event  does  not  form  by  itself  the  basis  of 
an  obsession,  but  the  recollection  of  an  unpleasant  occurrence 
may  awaken  in  the  patient  a  degree  of  expectancy  or  fear, 
and  this  emotional  state  becomes,  as  it  were,  the  nucleus  around 
which  obsessions  may  develop.  In  the  majority  of  the  im- 
perative processes  the  element  of  futurity  is  always  present. 
Theoretically,  the  difference  between  the  fixed  idea  and  the 
imperative  idea  is  that  the  latter,  more  or  less  suddenly  and 
without  any  relation  to  what  has  gone  before,  overwhelms 
consciousness,  whereas  the  former  develops  more  gradually 
and  is,  in  a  measure,  a  result  of  associative  thinking.  The 
fixed  idea,  granting  the  truth  of  the  premise  upon  which  it  is 
based,  is  characterized  by  a  logical  development,  the  impera- 
tive idea  is  abrupt  and  illogical. 

Wernicke  attempts  to  differentiate  autochthonous  from 
exaggerated  (iiberwertig)  ideas.  The  latter,  he  thinks,  are 
distinguishable  from  the  former  in  never  being  recognized  by 
the  patient  as  strange  and  inexplicable  intrusions  into  con- 
sciousness. Although  they  are  frequently  most  annoying  and 
persistent,  patients  do  not  recognize  them  as  abnormal.     Ac- 


ANOMALIES    OF   VOLITION 


103 


cording  to  the  same  view,  in  exaggerated  ideas  the  pathologi- 
cal element  in  their  genesis  and  in  their  content  is  not  admitted 
by  the  patient,  as  it  frequently  is  in  imperative  ideas  or  repre- 
sentations. It  may  be  admitted  that  occasionally  patients  are 
capable  of  distinguishing  autochthonous  thoughts,  whose 
content  is  strange  and  mystifying,  from  obsessions  whose 
sudden  and  inexplicable  appearance  in  itself  emphasizes  to 
the  patient  their  abnormality.  In  many  cases  it  is  impossible 
to  adopt  such  a  rigid  classification  of  these  phenomena.  Wer- 
nicke affirms  that  autochthonous  ideas  are  distinguishable 
from  obsessions  in  that  the  former  are  recognized  as  foreign 
to,  and  arising  outside  of,  the  individual  personality,  and  on 
this  account  are  believed  to  dominate  more  than  do  the  latter 
the  whole  of  the  psychic  life. 

It  has  already  been  noted  that  the  content  of  the  obsession, 
although  it  frequently  exerts  an  important  influence  upon  the 
patient,  has  practically  no  relation  to  the  ideas  that  have  im- 
mediately preceded  it  in  consciousness.  Instead  of  being  an 
active  impulse  which  diverts  and  transforms  a  train  of  thought, 
it  is  more  analogous  to  an  inhibitory  impulse  which  delays  and 
disorganizes  associative  thinking.  It  is  an  obstacle  to  pro- 
gressive thinking.  The  idea  can  not  be  banished  from  con- 
sciousness, and,  as  a  result  of  this  phenomenon,  fear,  expec- 
tancy, doubt,  and  isolated  incomprehensible  representations 
overwhelm  and  cloud  the  intellectual  processes.  The  effect 
of  the  obsession  upon  the  other  psychological  processes  is  not 
only  irritating,  but  paralyzing.  This  is  particularly  true  in 
the  case  of  individuals  where  the  normal  associative  thinking 
is  defective. 

Arnaud 55  calls  attention  to  the  fact  that  an  obsession 
is  in  reality  an  extremely  complicated  phenomenon.  It  is 
characterized  by  a  series  of  actions  and  reactions  which  pro- 
foundly affect  the  whole  mental  life  as  well  as  the  organic 
functions  causing  disorder  in  the  dynamics  of  the  associative 


60  Arch,  de  Neurologic   Sur  la  Theorie  de  1'Obsession.     Avril,   1902, 
P-  257- 


104  PSYCHIATRY 

mechanism  of  the  brain.  This  is  seen  in  the  disturbance  of 
some  or  all  of  the  voluntary  processes,  including  the  higher 
intellectual  functions.  An  imperative  representation  may  be 
defined  as  a  deficient  mental  synthesis, — an  abulia.  Arnaud 
affirms  that  the  emotional  as  well  as  the  purely  intellectual 
element,  the  idea,  both  play  an  important  but,  nevertheless, 
secondary  part  in  its  pathogenesis.  According  to  this  theory, 
the  emotional  element  is  measured  by  the  intensity  as  well  as 
by  the  character  of  the  "  crises  angoissantes"  which  accompany 
the  obsession,  but  it  is  never  the  causative  factor.  Patients 
subject  to  these  phenomena  are  conscious  of  their  inability  to 
banish  the  obsession  from  their  consciousness.  They  live  in 
apprehension  of  its  return  and  this  fact  conditions  their  emo- 
tional state.  The  idea,  in  a  measure,  determines  the  formal 
character  of  the  obsession.  But  the  influence  exerted  by  the 
idea  itself  is  directly  proportional  to  the  degree  to  which  voli- 
tion is  impaired.  When  the  voluntary  impairment  is  marked, 
the  obsession  attains  greater  significance.  Especially  is  this 
true  if  the  idea  or  representation  is  the  immediate  incentive  to 
action.  If  it  is,  the  case  becomes  of  forensic  importance.  The 
compulsive  acts  which  depend  upon  imperative  representations 
or  ideas  must  be  carefully  distinguished  from  those  that  are 
motiveless  and  the  result  of  pure  impulse.  According  to 
Ziehen,56  the  latter  are  also  compulsory,  but  are  motiveless  and 
do  not  depend  directly  upon  pathological  emotional  states, 
sensory  anomalies,  or  representations.  The  impulsive  act 
has  no  corresponding  state  of  consciousness  in  which  an  idea 
of  its  abnormality  is  present.  After  its  completion  there  is  an 
intact  memory  and  an  undiminished  power  of  retrospection. 

Considerable  attention  has  been  devoted  by  some  clinicians 
to  the  evolution  of  the  obsession  and  to  a  discussion  of  the 
part  played  by  these  phenomena  in  the  genesis  of  various  forms 
of  alienation.  Falret  and  Menier  affirm  that  an  obsession  is 
never  so  transformed  as  to  become  an  important  factor  in  the 

56  Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  xi,  Heft  i. 


ANOMALIES    OF   VOLITION 


I05 


clinical  picture  of  delirious  states.     This  observation  has  not 
been  generally  confirmed.57 

Cases  not  infrequently  come  under  observation  where  the 
delirious  state  seems  to  be  a  direct  evolution  from  the  obses- 
sions. There  is  reason  to  believe  that  obsessions  are  of  prime 
importance  in  the  evolution  of  certain  forms  of  melancholia, 
mental  confusion,  the  delire  onirique,  and  in  certain  system- 
atized deliria.  Again  there  are  cases  where  the  persistence  for 
a  considerable  period  of  time  of  these  obsessions  has  given 
rise  to  states  of  mental  depression  of  varying  degree.  For 
example,  a  patient,  who  was  much  prostrated  physically  by 
long-continued  nursing  of  a  member  of  her  family  afflicted  with 
cancer,  gradually  began  to  notice  that  the  impulse  to  wash  her 
hands  came  to  her  at  short  intervals.  The  foolishness  of  these 
repeated  acts  was  recognized  by  the  patient,  but  the  obsession 
continued  and  was  a  source  of  great  annoyance  to  her.  She 
became  greatly  depressed  as  a  result  of  this  impulse  and  feared 
that  if  it  continued  she  would  lose  her  mind.  Although  admit- 
ting that  the  frequent  repetition  of  these  washings  was  absurd, 
she  affirmed  that  she  was  unable  to  resist  the  impulse.  Ob- 
servers have  directed  attention  to  the  part  played  by  similar 
obsessions  in  the  disorganizing  of  associative  thinking.  The 
probable  part  played  by  obsessions  in  the  development  of  para- 
noia is  discussed  under  that  head. 

The  following  provisional  grouping  of  these  phenomena 
by  Loewenfeld  58  forms  a  satisfactory  clinical  basis  for  their 
study : 

A.  Those  in  the  intellectual  sphere,  which  may  be  divided 
into  two  categories : 

( 1 )   More  or  less  isolated  and  independent  obsessions 

including  imperative  ideas,  in  the  narrower  sense  of  the 


67  Seglas,  J. :  Soc.  med.-psych.,  seance  du  26  fevrier,  1901 ;  note  sur 
revolution  des  obsessions  et  leur  passage  au  delire.  Arch,  de  Neurol.,  vol. 
xv,  2e  serie,  1903,  No.  85  (Janvier). 

08  Loewenfeld,  L. :  Die  psychischen  Zwangserscheinungen.  Wiesbaden, 
1904. 


106  PSYCHIATRY 

word,    imperative   sensations,    and   imperative   hallucina- 
tions. 

(2)  The  obsessive  ideas  of  a  more  complicated  form 
of  mental  activity,  such  as  the  forced  questioning,  folie  du 
doute,  imperative  remembrances,  compulsory  thinking,  ex- 
cessive introspection. 

B.  The  imperative  processes  which  are  chiefly  character- 
ized by  anomalous  emotional  reactions,  apprehensiveness  with 
or  without  definite  fears,  imperative  emotional  states  and 
moods. 

C.  The  imperative  phenomena  associated  with  the  motor 
discharge,  impulses,  a  great  variety  of  simpler  movements  as 
well  as  more  complicated  acts,  and  inhibitory  processes. 

Impulsivity. — The  normal  behavior  of  an  individual  may 
be  profoundly  disturbed  as  the  result  of  impulses  which  may 
assume  a  great  variety  of  forms  and  give  rise  to  complications, 
many  of  which  are  of  forensic  importance.  The  mechanism  of 
these  impulses  is  not  essentially  different  from  that  occurring 
in  the  normal  individual.  All  grades  exist,  varying  from  those 
which  can  scarcely  be  called  abnormal  to  those  which  are  asso- 
ciated with  the  commission  of  the  most  brutal  and  disgusting 
crimes.  From  a  clinical  stand-point  these  impulses  may  be 
divided  into  those  with  disparate  and  those  with  coinciding 
motives.  In  speaking  of  the  disturbances  that  occur  in  organic 
sensibility,  it  was  shown  how  the  ordinary  sensations  attending 
hunger,  thirst,  rest,  and  activity  are  sometimes  perverted  during 
the  course  of  an  alienation,  and  this  change  in  the  ccensesthesia 
may  be  the  basis  of  impulsivity.  These  forced  acts  may  pro- 
duce results  of  a  more  or  less  indifferent  character  or  they  may 
be  attended  by  danger  either  to  the  individual  or  to  others. 
An  illustration  of  the  former  class  is  the  impulse  to  keep  in 
motion  noted  in  nervous  individuals  and  so  frequently  mistaken 
for  normal  healthy  activity.  These  abnormal  impulses  of  a 
more  or  less  harmless  character  occur  in  a  great  variety  of 
conditions,  in  hysteria  as  well  as  in  the  initial  stages  of  various 
other  psychoses.  Frequently  in  the  prodromal  period  of  manic- 
depressive  insanity  there  is  a  marked  tendency  for  the  indi- 


ANOMALIES    OF   VOLITION 


107 


vidual  to  be  continually  on  the  move.  Again,  some  of  these 
individuals,  apparently  without  any  good  and  sufficient  motive, 
will  sit  down  and  write  page  after  page.  Reference  has  been 
made  to  the  various  other  impulses  in  the  consideration  of  the 
psychasthenic  states.  Among  the  many  acts  which  are  asso- 
ciated with  danger  to  the  individual  or  those  who  surround 
him  only  a  few  of  the  more  important  need  be  mentioned  here. 
For  instance,  certain  individuals  show  a  tendency  to  steal  at 
any  and  all  times — kleptomania — or  to  set  fire  to  property — 
pyromania.  Both  of  these  vices  are  common  in  the  large  class 
of  individuals  who  are  broadly  designated  as  degenerates,  as 
well  as  in  epilepsy,  senile  conditions,  and  a  variety  of  other 
forms  of  alienation.  Suicidal  impulses  are  not  infrequent,  and, 
as  a  rule,  are  much  more  common  than  the  homicidal  forms. 
In  a  consideration  of  the  former  we  have  to  distinguish  be- 
tween those  which  are  and  those  which  are  not  the  result  of 
deliberation.  The  former  are  not  infrequently  met  with,  par- 
ticularly in  cases  of  hysteria  and  in  the  very  early  stages  of 
alienation,  at  a  time  when  the  patient  is  particularly  susceptible 
to  suggestion.  The  impulse  is  closely  related  to  a  tendency 
shown  by  nervous  individuals  to  jump  from  high  places.  As 
a  rule,  the  suicidal  tendency  in  these  instances  is  a  matter  of 
purely  momentary  suggestion.  Cases  are  on  record  where  the 
mere  sight  of  a  sharp  instrument,  of  a  hammer,  or  of  fire-arms 
has  been  sufficient  to  prompt  the  individual  to  attempt  violence 
upon  himself.  The  homicidal  impulse,  as  has  already  been 
said,  is  relatively  less  common.  In  all  probability  Loewenfeld's 
view  is  correct  that  the  homicidal  impulse  is  never  preceded 
by  a  fear  frequently  expressed  by  nervous  individuals  that 
they  may  do  bodily  harm  to  those  about  them,  but  comes  sud- 
denly and  with  overwhelming  force.  It  may  be  suggested,  just 
as  in  the  case  of  the  suicidal  impulse,  by  the  sight  of  fire-arms, 
sharp  instruments,  an  exposed  part  of  the  body,  such  as  the 
throat  or  the  neck.  Undoubtedly  the  mental  pictures  evoked  by 
the  revolting  details  of  murder  trials,  as  published  in  the  daily 
press,  have  occasionally  been  sufficient  to  drive  ill-balanced  indi- 
viduals to  commit  suicide,  and  less  frequently  homicide. 


108  PSYCHIATRY 

The  sexual  impulses  assume  a  great  variety  of  different 
forms  and  may  play  an  important  part  in  the  symptomatology 
of  several  forms  of  alienation.  Exhibitionism  is  frequently 
noted,  particularly  in  the  early  stages  of  senile  and  paralytic 
dementia.  Vices  due  to  perverted  sexual  sensation — paeder- 
asty, nekrophilia,  zoophilia,  sadismus,  and  masochismus — the 
latter  two  designated  collectively  as  algolagnia  (v.  Schrenk- 
Notzing) — have  been  carefully  investigated  by  a  large  number 
of  alienists  59  and  are  frequently  of  forensic  importance. 

VII.  DISTURBANCES    IN   THE    EMOTIONAL   REACTIONS.60 

Accurately  to  define  an  emotion  in  a  single  phrase  is  as 
impossible  as  to  give  an  exact  definition  of  the  phenomena  of 
consciousness,  intellect,  or,  in  fact,  of  any  expression  that  is 
used  in  a  relative  sense.  The  emotions  are  singularly  complex 
compounds  that  derive  their  importance  largely  from  the  ac- 
companying neural  disturbances.  They  consist  of  a  complex 
series  of  phenomena  which  give  rise  to  symptoms  that  only 
in  a  general  way  are  distinctive ;  and  for  this  reason  the  alien- 
ist should  be  exceedingly  guarded  in  attempting  to  describe 
their  characteristics  in  general  terms.  Each  case  must  be 
studied  on  its  own  merits,  and  few,  if  any,  rules  can  be  laid 
down  as  guiding  principles.  An  incident  stimulus  gives  rise 
to  a  certain  feeling,  and  this  in  turn  to  a  desire,  an  act,  and 
a  subsequent  sense  of  satisfaction  or  dissatisfaction,  according 
as  the  wish  is  gratified  or  not;  and  to  this  complex  of  sen- 
sations others  may  be  added  until  the  links  in  the  chain  of 
mental  processes  become  too  numerous  to  analyze.61  When  a 
stimulus  acting  under  normal  conditions  impinges  upon  the 
cerebral  cortex  with  sufficient  intensity  for  us  to  become  con- 

58  Eulenberg,  A. :    Sadismus  und  Masochismus. 

80  Morel :  Du  delire  emotif  nerveux  du  systeme  nerveux  ganglionnaire 
visceral.  Archiv  gener.  de  med.,  1866.  Ribot:  The  Psychology  of  the 
Emotions,  1897.  Sergi:  Dolore  e  Piacere,  Les  Emotions,  1901.  Finzi : 
Die  normale  Schwankungen  der  Seelenthatigkeiten  (Deutsch  von  Jentsch), 
1900. 

61  Die  Laune — Eine  Aerztliche-psychologische  Studie.  Jentsch,  Wies- 
baden, 1902. 


ANOMALIES    OF    EMOTION 


109 


scious  of  it,  a  concomitant  series  of  phenomena  can  be  noted. 
To  facilitate  description,  for  the  sake  of  convenience,  these 
may  be  divided  into  two  groups — mental  and  physical.  If, 
for  example,  the  finger  is  pricked  with  a  needle,  there  are  cer- 
tain objective  facts  that  may  become  obvious.  There  may  be 
a  change  in  the  facial  expression  indicative  of  pain,  accom- 
panied or  followed  by  a  series  of  complicated  muscular  con- 
tractions resulting  in  the  drawing  away  of  the  hand.  Con- 
nected with  these  objective  phenomena  are  those  that  are  com- 
monly described  as  subjective  in  character. 

These  two  classes  of  phenomena — psychic  and  physical — 
are  always  present  in  emotional  reactions,  although  the  rela- 
tive importance  of  the  two  is  never  constant  and  has  been 
variously  estimated  by  different  observers.  A  series  of  optic 
stimuli  may  give  birth  to  a  definite  and  well-defined  sense  of 
fear.  Here  the  primary  visual  stimulus  has  associated  with 
it  memory-pictures,  sensations,  and  a  chain  of  neural  disturb- 
ances, all  of  which  we  refer  to  collectively  as  fear.  The  bodily 
changes  are  a  cold  and  clammy  skin,  blanching  of  the  counte- 
nance, increase  in  the  rapidity  of  the  pulse,  and,  it  may  be, 
a  marked  tremor.  The  psychic  concomitants  are  manifold. 
There  may  be  only  an  indefinite  sense  of  anxiety  or  fear;  or 
it  may  be  that  the  possible  effects  of  some  supposedly  imminent 
disaster  are  pictured  in  rapid  succession  and  with  considerable 
detail.  These  phenomena  vary  in  individuals,  and  their  inten- 
sity and  extent  are  not  constant,  but  fluctuate  at  different  times 
in  the  same  person. 

Not  only  is  it  important  that  the  physician  should  study 
the  changes  in  the  organic  reactions,  both  mental  and  physical, 
that  are  to  be  observed  in  cases  of  alienation,  but  he  must  first 
familiarize  himself  with  the  fluctuations  that  occur  in  the  life 
of  the  normal  individual.  In  this  way  alone  will  he  be  able 
to  understand  many  of  the  changes  which  occur  during  the 
course  of  alienation.  In  many  instances  the  latter  are  simply 
to  be  regarded  as  representing  an  intensification  of  those  re- 
actions which  have  persisted  during  the  whole  life  of  the 
individual.     Take,  for  example,  the  periods  of  depression  to 


HO  PSYCHIATRY 

which  so  many  persons  are  subject.62  One  person  may  endure 
a  series  of  misfortunes  without  any  marked  tendency  to  be- 
come really  depressed,  whereas  in  another  every  trifle  serves 
to  disturb  the  mental  equilibrium.  These  varying  moods  are 
of  such  frequent  occurrence  in  nearly  every  individual  that 
they  cannot  be  considered  as  abnormal.  Thus  in  patients  who 
for  a  considerable  time  have  been  subjected  to  severe  discom- 
fort or  even  pain,  we  shall  often  find  that  on  the  cessation  of 
the  irritation  a  reaction  characterized  by  excitement  and  a 
certain  sense  of  exhilaration  follows.  These  reactive  phases 
are  not  infrequently  met  with  in  convalescents  from  some  pro- 
tracted disease,  such  as  typhoid  fever.  As  has  frequently  been 
suggested,  the  slight  exaltation  that  exists  in  cases  of  phthisis 
may  be  referable  to  some  form  of  autointoxication.  The 
anomalous  emotional  states  that  follow  protracted  mental  and 
physical  fatigue  are  well  known.  In  many  instances  the 
fatigue  causes  paresthesias  in  the  field  of  body  consciousness 
which  are  at  the  basis  of  the  irritability  and  discomfort  ex- 
hibited by  many  individuals. 

The  affective  disorders  are  sometimes  aggravated  by 
anomalous  mental  states,  more  especially  following  hallucina- 
tions. The  objective  signs  of  anxiety  or  fear  exhibited  by 
patients  who  are  the  subject  of  delusions  are  of  this  class. 
The  opposite  condition  is  not  infrequently  met  with.  There 
may  be  a  gradual  or,  at  times,  a  sudden  and  spontaneous  change 
in  the  physical  condition  of  the  patient.  As  a  result  of  this 
state  the  power  of  connected  thinking  is  limited  or  for  the 
time  completely  inhibited.  In  both  instances  the  extent  of 
the  reaction  depends  upon  the  functional  capacity  of  the  cen- 
tral nervous  system.  In  the  former  case  the  neural  disturb- 
ances predominate,  while  in  the  latter  the  disorganization  and 
dissociation  of  thought  become  the  more  important  feature. 
The  physical  changes  upon  which  both  series  of  phenomena 
depend  disorganize  or  inhibit  the  cortical  functions.     Whether 

62  Lange,  C. :    Periodische  Depressionszustande  und  ihre  Pathogenesis. 
Deutsch  von  H.  Kurella,  1896. 


ANOMALIES    OF   EMOTION  III 

the  so-called  psychic  or  the  neural  disturbances  dominate,  the 
clinical  picture  depends  upon  individual  idiosyncrasies. 

As  has  repeatedly  been  pointed  out,  our  emotions  are 
highly  developed  compounds,  which  it  is  frequently  impossible, 
in  view  of  the  few  facts  at  our  command,  to  analyze  clinically 
in  their  entirety.  In  the  case  of  certain  emotional  disturbances 
it  is  sometimes  possible  to  trace  their  rise  from  a  sensation  or 
feeling  comparatively  simple  in  origin.  About  this  feeling 
as  a  nucleus  are  clustered  other  sensations,  or  it  may  be  groups 
of  sensations,  which  vary  in  character.  All  of  these  may  be 
united  into  one  symptom-complex.  The  complexity,  no  less 
than  the  intensity,  of  these  highly  organized  reactions  depends 
directly  upon  the  functional  capacity  of  the  central  nervous 
system.  The  same  idea  may  be  differently  expressed  by  say- 
ing that  the  emotional  display  of  an  individual  is  conditioned 
by  that  series  of  events  which  has  directly  affected  the  develop- 
ment of  the  central  nervous  system.  The  child  at  birth  can- 
not be  said  to  be  an  emotional  creature.  It  is  true  that  it 
cries  in  response  to  a  stimulus,  but  this  cry  expresses  neither 
pleasure  nor  pain.  The  physical  phenomena  are  present,  but 
the  ideational  part  of  the  emotional  display  is  absent.  In  the 
adult  the  conditions  are  different.  As  the  nerve-cells  and 
fibres  in  the  cerebral  cortex  become  functionally  active,  a  series 
of  phenomena  are  noted  in  the  child  that  are  the  result  of  the 
greater  elaboration  and  working  up  of  the  stimulus  by  the 
cortical  elements  prior  to  its  discharge  as  an  efferent  impulse, 
and  gradually  in  the  course  of  development  he  becomes  accus- 
tomed to  respond  in  a  definite  manner  to  different  forms  of 
stimuli.  Certain  neural  inclinations  are  established,  and  in 
time  the  growing  brain  responds  more  easily  to  one  kind  of 
a  stimulus  than  it  does  to  another.  Finally,  when  the  prime 
of  life  is  reached,  it  is  seen  that  the  functional  capacity  of  the 
central  nervous  system  of  one  individual  differs  essentially 
from  that  of  other  persons.  Certain  neural  inclinations  have 
been  established  and  the  power  of  inhibiting  or  initiating  the 
cortical  functions  has  received  a  definite  trend.  One  of  the 
chief  aims  of  education  should  be  to  adapt  the  emotional  reac- 


112  PSYCHIATRY 

tions  of  an  individual  to  his  environment.  These  reactions 
must  not  be  excessive  nor  incongruous.  The  nervous  system 
must  be  trained  to  ignore  the  action  of  certain  irritating 
stimuli.  Hypersensitiveness  and  misery  are,  in  a  measure, 
synonymous  terms.  The  proper  development  through  edu- 
cation of  the  nervous  system  of  neural  inclinations  or  dis- 
inclinations is  a  matter  of  prime  importance. 

In  the  adult  the  mental  processes  have  different  shades 
and  degrees  of  coloring.  This  is  commonly  expressed  by 
saying  that  each  thought  and  act  has  its  accompanying  mood. 
These  moods  or  states  are  the  qualifying  factors  in  "sensations 
due  either  to  intra-  or  extra-organic  stimuli.  A  given  sensa- 
tion may  be  attended  by  a  sense  of  pleasure,  but  if  its  intensity 
is  increased  and  its  duration  prolonged,  a  definite  sense  of 
pain  develops,  thought  is  disorganized,  and,  as  a  result,  doubt, 
instability,  or  anger  may  result. 

The  manner  in  which  the  organism  reacts  to  stimuli  con- 
ditions the  appearance  of  the  mood.  The  reactions  are  in  part 
the  result  of  congenital  factors  and  in  part  of  trends  acquired 
through  education  and  environment.  In  normal  thought  and 
action  there  is  deliberateness,  no  incongruity,  no  sudden  ces- 
sation or  break  in  the  physiological  processes.  In  alienation 
the  reverse  is  true.  Thus  impulses,  imperative  conceptions, 
or  strange  organic  sensations  break  in  upon  and  inhibit  or 
repress  a  line  of  thought  or  action.  The  dominant  note  of 
the  mood  is  frequently  characterized  by  great  permanence  and 
a  marked  tendency  to  reiteration.  All  forms  of  stimuli  seem 
to  intensify  but  not  to  alter  its  form.  The  patient  who  suf- 
fers from  mental  depression  sinks  deeper  into  his  gloom  when- 
ever he  is  stimulated;  it  matters  little  what  the  character  of 
the  sensation  may  be.  A  waltz  or  a  comic  song  is  quite  as 
apt  to  increase  the  intensity  of  mental  pain  as  the  sound  of 
a  dirge  or  funeral  anthem.  The  same  principle  holds  in  cases 
of  exaltation.  Everything  serves  to  magnify  the  sense  of  well- 
being  and  to  add  to  the  feeling  of  exhilaration.  No  event  is 
too  solemn,  no  situation  too  serious,  to  detract  from  the  levity 
and  buffoonery  of  some  maniacal  patients. 


ANOMALIES    OF   EMOTION 


113 


Mood  is  a  collective  term  used  to  express  the  mental  tone 
accompanying  a  thought  or  act.  It  indicates  the  existence  of 
modifications  that  have  taken  place  in  the  process  of  the  work- 
ing up  and  elaboration  of  stimuli.  Moods  tend  to  persist, 
since  the  equilibrium  is  only  gradually  restored  to  the  normal. 
In  cases  of  disease  this  persistence  of  definite  mental  tones 
is  often  exaggerated.  The  mood  once  established  becomes  in 
a  measure  permanent.  It  gives  direction  to  the  whole  train 
of  thought.  Out  of  the  various  organic  needs  pressing  for 
satisfaction  develops  the  mood,  and  this  in  turn  dominates  for 
the  time  the  whole  field  of  psychic  activity.  To-day  all  forms 
of  stimuli  seem  to  give  rise  to  disagreeable  ideas.  The  whole 
mental  attitude  is  one  of  depression,  but  a  night's  rest  changes 
the  whole  character  of  our  mentality.  By  common  consent 
certain  moods  are  designated  by  definite  terms,  such  as  pleas- 
urable, painful,  etc. 

Some  observers  maintain  that  a  sensory  impression,  as  it 
appears  in  consciousness,  is  associated  either  with  a  sense  of 
pleasure  or  pain,  but  such  a  view  exaggerates  the  importance 
of  these  two  tonal  elements.  It  is  possible  that  as  the  result 
of  our  environment  and  education  our  nervous  system  re- 
sponds without  effort  to  certain  kinds  of  stimuli.  A  mental 
reaction  which  in  one  individual  may  be  accompanied  by  a 
distinct  sensation  of  pleasure  or  pain  in  another  is  neutral. 
From  this  it  is  not  justifiable  to  draw  the  inference  that  nor- 
mal thought  or  action  is  completely  unaccompanied  by  neural 
disturbance,  but  rather  that  a  stimulus  which  in  one  individual 
is  attended  by  a  series  of  complicated  psychic  and  physical 
reactions,  a  sense  of  conscious  effort,  and  a  needless  expendi- 
ture of  energy  may  in  another  person  fail  to  elicit  evidences 
of  great  neural  disturbance. 

The  diminution  or  impairment  of  the  objective  emotional 
reactions  is  frequently  noted  in  cases  of  alienation.  In  im- 
beciles or  idiots  an  imperfect  development  of  the  cerebral  cor- 
tex may  be  responsible  for  the  persistence  of  a  less  complicated 
psychic  and  yet  more  intense  physical  reaction.  The  imper- 
fections and  intensity  of  the  emotional  displays  of  childhood 


ii4 


PSYCHIATRY 


are  well  known.  In  children  the  defect  in  the  mental  elabo- 
ration of' the  stimulus  is  characteristic.  What  may  be  termed 
the  neural  reactions  are  well  developed,  but  the  psychic  are  in 
abeyance.  Those  who  suffer  from  congenital  or  acquired  de- 
fects of  the  central  nervous  system  are  particularly  liable  to 
emotional  storms  of  great  intensity,  owing  to  the  decreased 
power  of  inhibition.  On  the  other  hand,  the  so-called  higher 
or  intellectual  emotions  are  only  developed  to  a  limited  extent. 

In  the  earlier  stages  of  dementia  prsecox  there  is  marked 
impairment  in  the  intellectual  side  of  the  emotional  reactions. 
In  fact,  the  essential  characteristic  of  this  disease  is  said  by 
Stransky  to  be  the  dissociation  between  the  idea  and  the  corre- 
sponding emotional  reaction — an  intrapsychic  incoordination. 
In  some  cases  any  form  of  sensory  stimulation  may  give  rise 
to  incongruous  and  intense  reactions.  Thus  some  patients 
while  sobbing  will  nevertheless  affirm  that  they  feel  in  the  best 
of  spirits  or  laugh  when  there  is  absolutely  no  occasion  for 
any  display  of  mirth.  Their  attitude  towards  their  surround- 
ings changes ;  they  become  unsociable  and  appear  to  have  lost 
all  affection  for  their  friends  and  even  for  members  of  their 
family.  As  the  disease  progresses  they  become  more  and  more 
emotionally  indifferent,  until  finally  only  those  reactions  are 
retained  that  are  the  immediate  expression  of  the  physical 
needs  of  the  organism. 

In  some  cases  the  patient  is  conscious  of  his  limitations, 
and  recognizes  that  his  emotional  state  is  anomalous.  This 
is  more  apt  to  be  the  case  in  hysterical  or  neurasthenic  indi- 
viduals than  in  the  earlier  stages  of  a  condition  that  even- 
tually is  to  develop  into  a  pure  psychosis.  In  the  latter  an 
apathy  often  comes  on  synchronously  with  the  change  in  the 
emotional  tone,  whereas  a  neurasthenic  patient  not  infre- 
quently affirms  that  he  has  lost  interest  in  his  surroundings 
and  friends ;  that  his  ideals  are  things  of  the  past ;  and  he  is  apt 
to  be  depressed  mentally  by  the  consciousness  of  this  subjective 
disorder.  The  defects  in  the  emotional  life  of  individuals  are 
often  associated  with  a  tendency  to  an  exaggeration  of  the 
reactions  that  are  retained. 


ANOMALIES    OF   EMOTION  115 

An  increase  in  the  intensity  and  volume  of  the  physical 
reactions  in  the  emotional  display  is  characteristic  of  various 
forms  of  mental  disturbances.  On  the  other  hand,  the  imme- 
diate effect  of  a  stimulus  upon  an  over-susceptible  nervous 
system  may  be  almost  a  complete  inhibition  of  the  associated 
functions  of  the  brain.  The  individual  may  even  lose  con- 
sciousness or  the  cortical  functions  may  be  only  partially  in- 
hibited, giving  rise  to  a  state  of  confusion.  Intense  emotional 
reactions  are  not  uncommon  in  neurasthenics.  These  indi- 
viduals, by  their  environment  and  training,  have  little  capa- 
bility for  ignoring  irritants.  They  are  hypersensitive  and 
exhibit  to  a  marked  degree  the  evils  of  interpreting  pleasure 
and  pain  merely  in  terms  of  sensation.  The  slightest  external 
stimulus  serves  to  direct  their  attention  to  themselves,  and 
there  it  remains  fixed  until  diverted  by  a  stronger  irritant. 
Their  lack  of  mental  equilibrium  is  often  characterized  by  in- 
tense anxiety,  grief,  pleasure,  and  pain,  which  succeed  each 
other  with  great  rapidity.  Emotional  instability  and  its  con- 
comitant reactions  are  exhibited  by  many  epileptics,  who  on 
the  slightest  provocation  are  intensely  pleased  or  greatly  dis- 
pleased. Again,  the  epileptic  is  apt  to  be  capricious,  and  not 
uncommonly  is  the  subject  of  sudden  and  inexplicable  out- 
bursts of  temper. 

The  excessive  volume  and  intensity  of  the  emotional  re- 
actions in  the  insane  are  not  infrequently  associated  with 
psycho-ansesthesias.  Thus  in  many  maniacal  patients  a  psycho- 
analgesia  is  readily  demonstrable,  the  patients  throwing  them- 
selves about  the  bed  or  the  room  and  often  inflicting  serious 
injuries  upon  themselves  without  giving  any  objective  evidence 
that  they  have  the  slightest  appreciation  of  painful  sensations. 
Even  when  the  actual  conduction  of  sensory  impulses  from  the 
periphery  is  not  impaired,  the  patient's  attention  is  sometimes 
so  firmly  riveted  upon  certain  objects  or  upon  the  execution 
of  certain  muscular  movements  that  peripheral  irritation  is 
ignored.  This  fact  doubtless  explains  the  cases  of  insane  per- 
sons who,  being  impressed  with  the  delusion  that  they  are 
superhuman,  inflict  severe  bodily  injury  upon  themselves.    The 


Il6  PSYCHIATRY 

spirit  of  exaltation,  the  tetanization  of  the  attention,  and  the 
resulting  psychic  analgesia  explain  the  deeds  of  many  self- 
torturers,  not  only  among  those  who  are  clearly  insane,  but  in 
certain  border-line  cases — for  instance,  those  of  fanatics  and 
many  so-called  martyrs.63  In  these  cases  stimuli  that  under 
normal  conditions  would  produce  marked  neural  disturbances 
fail  to  do  so  and  the  individual  remains  indifferent,  experi- 
encing neither  pleasure  nor  pain. 

The  study  of  the  objective  evidence  of  neural  disturb- 
ances in  the  emotional  reactions  is  important.  Thus  in  states 
of  exaltation  the  rhythm  of  the  breathing,  as  well  as  the 
character  of  the  cardiac  action,  is  altered.  The  secretion  of 
sweat  or  urine  is  often  interfered  with,  and  there  may  be 
marked  disturbances  of  function  of  the  voluntary  and  invol- 
untary musculature.  Exaltation  may  in  *a  measure  be  consid- 
ered antithetical  to  depression,  and  the  physiognomy  in  the 
two  states  is  essentially  different.  In  the  former  the  skin  over 
the  forehead  is  smooth  or  thrown  into  slight  horizontal  wrin- 
kles, the  eyebrows  are  elevated,  and  the  eyes  show  an  increase 
in  the  secretion  of  tears.  The  corners  of  the  mouth  are  raised. 
In  states  of  depression  the  condition  is  reversed.  In  young 
children,  idiots,  and  in  some  forms  of  dementia  the  neural 
disturbances  accompanying  states  of  depression  and  exaltation 
are,  in  a  measure,  similar.  The  effects  of  an  outburst  of  anger 
may  influence  the  whole  musculature.  If  the  reactions  are 
greatly  exaggerated,  there  may  be  a  complete  inhibition  of 
certain  motor  functions  followed  by  an  increase  in  the  inten- 
sity and  volume  of  others.  The  statement  that  in  the  former 
condition  there  is  a  high  intracranial  tension,  while  in  the 
latter  it  is  subnormal,  is  a  pure  hypothesis.  Unquestionably, 
in  many  instances  the  depression  is  associated  with  increased 
tension  in  the  peripheral  arteries  and  exaltation  with  the  oppo- 
site condition,  but  from  these  observations  alone  deductions 
regarding  the  state  of  the  cerebral  circulation  are  not  justifi- 
able.    As  a  rule,  those  emotional  displays  may  be  said  to  be 

63  Mercier  :    Psychology.  Normal  and  Morbid,  1901. 


ANOMALIES    OF   EMOTION  117 

abnormal  in  which  there  is  evidence  of  marked  dissociation 
of  the  cortical  functions. 

Considerable  variation  in  the  emotional  display  in  patients 
who  are  the  subjects  of  the  same  form  of  alienation  is  not 
infrequent.  For  example,  in  one  case  of  maniacal  excitement 
there  may  be  marked  motor  restlessness,  a  rapid  pulse,  tremor, 
and  all  the  objective  evidences  of  considerable  neural  disturb- 
ance, and  accompanying  the  physical  symptoms  the  character- 
istic rapid  flow  of  ideas  indicative  of  psychic  hyperesthesia. 
In  another  patient  there  may  be  a  marked  disproportionate- 
ness  between  the  physical  and  mental  concomitants  of  the  emo- 
tional instability,  sometimes  the  former,  and  again  the  latter 
predominating. 

Closely  associated  with  the  neural  disturbances  in  the 
anomalies  of  emotion  are  the  feelings  or  groups  of  sensations 
which  are  designated  moods  or  feeling-tones.  In  certain  in- 
stances, as  has  already  been  said,  these  moods  are  devoid  of 
color,  and  no  one  feeling  dominates  the  clinical  picture.  The 
patient  may  be  indifferent  or  apathetic.  In  certain  delirious 
states  the  apathy  is  broken  only  by  the  performance  of  acts 
that  are  apparently  the  result  of  various  impulses  depending 
upon  changes  in  the  organic  sensations.  In  other  cases  marked 
anxiety  is  the  dominating  symptom.  This  is  frequently  indefi- 
nite in  character,  the  patient  not  being  able  to  assign  any  cause 
for  his  mental  distress.  Some  clinicians  affirm  that  this  anx- 
iety, so  often  a  prominent  symptom  in  mental  disease,  pos- 
sesses the  characteristics  of  a  distinct  emotion  and  is  attended 
by  a  definite  sense  of  mental  pain.  In  the  majority  of  in- 
stances, however,  the  ideation  associated  with  the  neural  dis- 
turbance is  ill-defined.  Patients  in  this  state  frequently  declare 
that  they  cannot  describe  their  feelings.  The  investigations 
of  Kornfeld  64  are  of  interest  in  connection  with  the  determi- 
nation of  objective  evidences  of  neural  disturbances  in  cases 
in  which  anxiety  is  a  prominent  symptom.  Not  only  is  there 
marked  alteration  in  the  tone  and  functional  capacity  of  the 

64  Zur  Pathologie  der  Angst.    Jahrbiicher  f.  Psychiatrie,  Bd.  xxii. 


Il8  PSYCHIATRY 

skeletal  muscles,  but  this  functional  derangement  involves  the 
muscular  elements  in  the  walls  of  the  blood-vessels.  This  is 
shown  by  the  rise  of  blood-pressure  and  the  variations  in  char- 
acter of  the  pulse-wave.  The  anomalies  of  glandular  secre- 
tion are  particularly  noteworthy.  The  rapid  rise  in  blood- 
pressure  which  occurs  as  the  emotional  storm  gathers  is  fol- 
lowed by  an  equally  rapid  drop,  beginning  when  the  patient 
breaks  out  into  a  profuse  sweat. 

The  anxiety  of  cortical  origin  that  is  met  with  in  cases 
of  alienation,  according  to  Souque,65  should  be  sharply  dis- 
tinguished from  the  precordial  anxiety,  which  is  a  bulbar 
symptom.  The  latter  is  a  definite  symptom-complex,  charac- 
terized by  a  sense  of  depression  or  suffocation,  while  the  for- 
mer, equally  intense,  is  characterized  by  vague  apprehensive- 
ness.66  The  two  states  may  appear  independently  in  the  same 
case.  The  objectless,  indefinite  feeling  of  anxiety  so  common 
in  various  forms  of  alienation  not  infrequently  crystallizes 
into  fear.  This  change  may  be  due  to  the  occurrence  of  hallu- 
cinations or  delusions.  Lowenfeld  has  suggested  the  follow- 
ing classification  of  the  various  states  of  anxiety. 

(i)  Those  relating  to  the  health  of  the  individual.  (2) 
Those  in  which  there  is  excessive  apprehensiveness  in  regard 
to  questions  connected  with  ethics  and  morality.  (3)  Those 
relating  to  the  health  of  members  of  the  immediate  family 
or  friends.  (4)  Numerous  others  connected  with  the  indi- 
vidual's profession  or  particular  view  of  life. 

The  indefinite  crystallized  fears  are  most  noticeable  in 
cases  in  which  there  are  marked  hallucinatory  disturbances, 
such  as  those  due  to  alcohol,  cocain,  and  various  drug  intoxi- 
cations. The  phobias  associated  with  obsessions,  though  com- 
mon in  neurasthenics  and  hysterical  individuals,  never  give 
rise  in  these  patients  to  severe  emotional  storms  as  sudden  in 
their  onset  and  incongruous  in  their  nature  as  those  found  in 


85  Societe  de  Neurologie  de  Paris,  Decembre  4,  1902. 
M  The  difference  between  these  two  phenomena  is  indicated  by  French 
writers,    who    distinguish    between   angoisse    and    anxiete. 


ANOMALIES    OF    CONDUCT  119 

various  psychoses.  In  cases  of  depression  the  feeling-tone 
varies  from  the  mildest  to  the  most  intense  psychic  pain.  The 
feeling  of  mental  depression  may  be  secondary,  depending 
upon  the  occurrence  of  hallucinations  or  delusions,  as  is  the 
case  in  the  early  stages  of  melancholia  or  the  manic-depressive 
insanity.  The  mildest  forms,  those  without  motive  or  domi- 
nant idea,  and  on  this  account  called  primary,  are  met  with 
in  various  forms  of  nervous  and  mental  disease  as  well  as  in 
childhood  and  old  age. 

VIII.  ANOMALIES  OF  CONDUCT  WITH  ESPECIAL  REFERENCE 
TO   THE   SO-CALLED   MORAL   INSANITY. 

Somewhat  analogous  to  the  anomalies  of  connected 
thought  which  have  been  shown  to  be  related  to  the  develop- 
ment of  insane  ideas  are  the  various  disturbances  of  the  so- 
called  moral  and  ethical  sense.  In  1835  Pritchard  in  England 
first  suggested  the  term  "  moral  insanity"  to  designate  a  not 
very  uncommon  group  of  cases  in  which  the  acts  of  the  pa- 
tients are  characterized  at  times  by  startling  moral  obliquities. 
For  some  time  these  cases  were  regarded  as  forming  a  group 
by  themselves  owing  to  the  belief  that  they  possessed  many 
characteristics  in  common.  Long  before  Pritchard's  time,  how- 
ever, this  type  of  aberration  had  already  attracted  the  atten- 
tion of  alienists,  and  excellent  descriptions  of  it  are  to  be 
found  in  Pinel's  writings  under  the  head  of  mania  without 
delirium,  or,  as  Esquirol  called  it,  the  affective  or  instinctive 
monomania.  The  attitude  of  the  English  alienist  in  the  study 
of  the  problems  suggested  by  these  cases  was  largely  the 
result  of  the  psychology  of  the  day,  which  taught  that  the 
division  of  the  brain  functions  was  tripartite,  and  that  each 
of  these  was  characterized  by  more  or  less  independence,  so 
that  one  group  of  phenomena  in  the  realm  of  thought,  feeling, 
or  volition  might  be  seriously  interfered  with  without  causing 
a  disturbance  of  the  others.  The  Scotch  and  French  schools 
of  philosophy  had  also  inculcated  the  belief  in  the  existence 
of  a  definite  and  distinct  "  moral  sense"  that  was  capable  of 
distinguishing  between  good  and  bad,  just  as  the  touch  differ- 


120  PSYCHIATRY 

entiates  between  heat  and  cold  or  the  eye  between  black  and 
white.  Owing  to  the  study  of  cases  en  -masse  and  the  influence 
of  this  scholastic  type  of  psychology,  it  became  customary  to 
speak  of  the  ethical  and  moral  lapses  of  individuals  as  if  they 
were  to  be  regarded  as  isolated  defects  of  the  higher  cortical 
functions.  Gradually,  however,  physiologists  not  only  suc- 
ceeded in  analyzing  the  sensorial  processes,  but  were  also  able 
to  show  that  all  the  cerebral  functions  were  composite.  In 
the  light  of  these  investigations,  the  term  "  moral  insanity" 
came  to  be  looked  upon  merely  as  satisfying  a  provisional 
requirement  to  designate  a  certain  large  group  of  heterogene- 
ous cases.  At  the  same  time,  its  introduction  into  psychiatrical 
literature  was  of  historical  significance,  inasmuch  as  it 
amounted  to  a  tacit  assent  to  the  proposition  that  the  behavior 
of  an  individual  was  merely  an  expression  of  the  functional 
activity  of  the  central  nervous  system,  and  that  in  the  ultimate 
analysis  it  could  be  shown  that  "  men's  characters  must  be  in 
part  determined  by  their  visceral  structure." 

The  phenomena  concerned  in  the  study  of  human  conduct 
cannot  be  thought  out  by  the  metaphysician,  nor  is  any  reason- 
able person  willing  to  admit  that  the  categorical  imperative, 
or  "  the  still,  small  voice  of  conscience,"  are  any  longer  to  be 
regarded  as  satisfactory  explanations  for  the  behavior  of  an 
individual.  Only  as  the  result  of  patient,  painstaking  obser- 
vation are  we  gradually  getting  some  clue  to  the  motives  and 
agencies  which  are  at  work  in  determining  the  simplest  acts 
of  an  individual,  and  a  few  guiding  principles  have  already 
been  laid  down  that  are  of  use  in  directing  the  inquiry  con- 
cerning the  more  complicated  volitional  processes.  These  in- 
quiries necessarily  relate  to  the  nature  and  development  of 
individual  character  and  by  the  laity  are  supposed  to  deal  with 
the  cases  which  are  referred  to  as  occupying  the  boundary  line 
between  sanity  and  insanity.  As  a  matter  of  fact,  such  inter- 
mediate stages  never  exist.  An  individual  is  either  normal 
or  abnormal,  well  or  ill;  and  to  suppose  that  intermediate 
stages  exist  is  merely  playing  upon  words. 

As  certain  phases  of  this  problem  are  considered  else- 


ANOMALIES    OF    CONDUCT  I2i 

where  in  this  book,  we  propose  to  confine  the  present  discus- 
sion to  those  cases  in  which  the  element  of  choice  and  delib- 
eration seems  to  be  an  important  factor  in  conditioning  the 
behavior  of  an  individual.  We  may,  therefore,  exclude  at 
once  all  those  cases  in  which  the  acts  of  an  individual  are 
merely  the  result  of  chance  impulses  or  obsessions,  such  as 
the  impulsivity  that  is  so  common  in  the  dream  states  of 
hysterical  or  epileptic  conditions,  in  the  early  stages  of  de- 
mentia prsecox,  or  in  other  psychoses.  It  is  a  curious  com- 
ment upon  the  looseness  and  illogical  character  of  human 
reasoning,  that  while  an  individual  is  exculpated  for  a  crime 
when  it  is  proved  beyond  doubt  that  he  has  been  acting  merely 
as  the  result  of  a  blind  impulse,  the  plea  of  insanity  may  not 
be  entered  when  an  act  is  the  result  of  an  apparent  deliberation 
or  choice.  Suppose,  for  example,  that  a  crime  has  been  com- 
mitted by  a  man  who  possibly  for  months  has  deliberated  upon 
a  plan  of  action  and  has  finally  selected  the  one  best  adapted 
to  some  foul  end  and  where  no  evidence  will  be  left  behind 
which  will  incriminate  him.  Such  an  individual  undoubtedly, 
in  a  certain  sense,  indicates  more  plainly  than  does  the  person 
who  is  actuated  by  mere  impulse  that  his  cerebral  processes 
are  deficient  and  that  he  can  neither  think  nor  act  up  to  the 
current  standards  by  which  conduct  is  judged.  For  physiology 
teaches  us  that  only  individuals  possessing  the  most  complete 
functioning  of  the  higher  centres  are  capable  of  successfully 
inhibiting  many  morbid  tendencies  of  thought  or  action. 

One  duty  of  the  alienist,  therefore,  is  to  attempt  by  the 
aid  of  careful  investigation  to  throw  light  upon  the  biological 
factors  conditioning  the  determinism  upon  which  the  conduct 
of  individuals  depends.  Here  we  have  to  distinguish  between 
the  influence  exerted  by  personal  characteristics,  inherent  ten- 
dencies and  traits,  and  the  determinism  that  is  the  product  of 
environmental  agents.  A  sharp  distinction  can  not,  however, 
always  be  drawn  between  the  two,  and,  furthermore,  this 
problem  necessarily  involves  the  discussion  of  those  complex 
phenomena  of  heredity  to  which  reference  is  made  elsewhere. 
In  addition  to  the  more  remote  factors  that  determine  the 


122  PSYCHIATRY 

behavior  of  individuals,  the  clinician  has  to  consider  those 
that  act  more  directly  and  that  for  want  of  a  better  term  may 
be  called  the  immediate  provocative  agents.  Such,  for  exam- 
ple, are  the  physical  changes  that  occur  daily,  or  even  hourly, 
in  the  individual,  so  that  he  becomes  responsive  to  certain 
forms  of  stimuli  which  at  another  time  would  produce  little, 
if  any,  positive  reaction.  At  present  investigations  carried  on 
in  the  clinic  with  a  view  to  attempting  the  solution  of  this  and 
similar  problems  are  largely  casuistical  in  form.  Neverthe- 
less, much  important  information  may  be  gathered  from  stud- 
ies of  this  nature. 

In  taking  up  the  question  of  individual  behavior,  then,  we 
have  from  a  purely  practical  stand-point  to  consider  all  the 
events  or  conditions  that  influence  connected  thinking,  delib- 
eration, choice,  and  finally  the  act  or  series  of  acts  which  may 
be  regarded  as  the  culmination  of  these  processes.  Of  course, 
they  are  not  to  be  regarded  as  separate  and  distinct,  but  are 
merely  designated  empirically  by  the  terms  referred  to  in 
order  to  facilitate  description.  Certain  phases  of  this  question 
have  already  been  discussed  when  dealing  with  the  volitional 
processes.  Naturally,  each  case  must  be  studied  on  its  merits ; 
but,  broadly  speaking,  the  higher  the  intellectual  type,  the  more 
complicated  the  processes  of  conception,  deliberation,  and 
choice. 

In  order  to  arrive  at  any  real  understanding  of  the  be- 
havior of  individuals  it  is  essential  to  become  familiar  with 
the  slight  anomalies  in  conduct  which  so  frequently  come  under 
the  observation  of  the  physician  and  in  which  the  complexity 
of  the  phenomena  concerned  is  not  so  great  as  to  baffle  analy- 
sis. Let  us  consider  for  an  instant  the  possible  approaches 
that  may  be  made  to  the  study  of  the  conduct  of  an  individual 
who  is  imbued  with  the  spirit  of  pessimism.  Under  this  term 
may  be  grouped  together  all  those  philosophical  views  which 
affirm  that  suffering  and  pain  more  than  counterbalance  the 
sum  total  of  life's  pleasures  and  happinesses.  Certain  forms  of 
pessimism  find  their  immediate  expression  not  only  in  the 
countenance  but  also  in  the  acts  of  an  individual.     If  we  at- 


ANOMALIES    OF    CONDUCT 


123 


tempt  to  analyze  the  physical  condition  which  underlies  this 
view  of  life,  it  is  possible  to  bring  to  light  a  number  of  facts 
which  will  have  an  important  bearing  upon  the  mental  atti- 
tude of  the  individual  who  entertains  these  ideas.  In  certain 
forms  of  pessimism  it  is  at  once  noticeable  that  there  is  con- 
siderable impairment  of  the  volitional  processes,  and  individ- 
uals so  afflicted  give  expression  in  one  way  or  another  to  the 
subjective  sense  of  insufficiency  and  abulia.  They  not  infre- 
quently spend  their  time  in  lamentation.  It  is  easier  for  them 
to  cry  out  that  "  all  is  vanity  and  vexation  of  the  spirit"  than 
it  is  to  act.  Kowalewsky  67  has  gone  so  far  as  to  affirm  that 
the  asymmetry  in  the  relation  of  the  pleasure  and  pain  func- 
tions that  exists  in  pessimistic  individuals  is  the  underlying 
cause  which  determines  their  views.  Such  observations  can 
frequently  be  confirmed  in  the  clinic  by  the  study  of  the  large 
group  of  neurasthenic  individuals  who,  when  subjected  to  any 
additional  strain,  are  immediately  thrown  into  a  state  in  which 
anxiety,  apprehensiveness,  and  mental  depression  become  dom- 
inant factors  in  the  symptomatology.  In  the  more  severe 
cases  a  more  or  less  complete  change  in  the  whole  personality 
follows.  Another  important  factor  in  the  genesis  of  these 
conditions,  where  the  volitional  processes  seem  to  be  more 
or  less  interfered  with,  is  the  tendency  exhibited  by  such  indi- 
viduals to  excessive  mental  rumination.68  Up  to  a  certain 
point  the  judgment  and  critical  faculties  are  well  preserved, 
but,  as  Maudsley  long  ago  pointed  out,  action  seems  to  be 
blocked  by  the  tendency  exhibited  by  men  even  of  great  intel- 
lectual capacity  to  expend  their  energies  in  introspection  or 
in  the  minute  analyses  of  certain  trains  of  thought.  A  classic 
example  of  such  a  type  is  that  portrayed  in  Hamlet.  In  the 
transition  from  the  socially  disposed  pessimist  to  the  misan- 
thrope we  can  trace  a  gradual  unbroken  line,  as  we  can  be- 
tween the  latter  and  the  extreme  anarchist.  The  different  links 
in  the  chain  may  be  filled  in  by  careful  clinical  study. 

67  Kowalewsky :   Studien  zur  Psychologie  des  Pessimismus.   Wiesbaden, 
1904. 

68  La  Logique  morbide.    L' analyse  mentale.    N.  Vaschide,  Paris,  1903. 


124  PSYCHIATRY 

Similar  methods  of  investigation  are  also  applicable  to 
a  variety  of  other  conditions.  In  a  study  of  criminality,  just 
as  in  a  study  of  psychiatry,  progress  has  undoubtedly  been 
delayed  at  times  by  the  excessive  zeal  exhibited  by  a  few 
observers  in  their  desire  to  pick  out  and  formulate  definite 
types  which  they  would  judge  by  purely  arbitrary  standards. 
Imbued  with  this  idea,  Lombroso  attempted  to  create  a  special 
class,  as  it  were,  which  was  to  comprise  all  the  various  types 
of  criminals.  In  a  measure  these  delinquents  were  supposed 
to  be  fundamentally  different  from  the  normal  man,  and  were 
remarkable  not  only  for  their  vices  but  for  the  anomalies  in 
physical  structure  which  were  supposed  to  be  more  or  less 
distinctive.  Undoubtedly,  such  a  view  is  too  extreme  to  be 
accepted  literally.  In  studying  these  delinquents  such  a  great 
variety  of  factors  must  be  taken  into  account  that  it  becomes 
impossible,  except  in  a  very  general  way,  to  find  characteristics 
that  in  the  main  are  distinctive.  Nevertheless,  alienists  and  leg- 
islators have  come  to  recognize  a  class  of  individuals — incor- 
rigible recidivists,  predestined  to  lead  lives  of  violence  and 
crime — as  presenting  the  characteristics  of  Lombroso's  de- 
linquent. As  a  rule,  these  unfortunates  present  considerable 
mental  impairment  along  certain  lines;  they  are  subject  to 
vicious  impulses  and  are  apt  to  be  completely  deficient  in  sym- 
pathy and  altruistic  qualities.  Ferri  has  divided  them  into 
the  following  categories  :  ( i )  those  with  impaired  intelligence 
and  bad  congenital  tendencies;  (2)  those  in  whom  the  in- 
tellectual faculties  are  less  involved,  but  who  are  signally  ad- 
dicted to  debauchery,  vagabondage,  and  crime;  (3)  those 
who  are  unable  to  persevere  in  any  serious  occupation  during 
life,  who  show  deliberateness  in  the  manner  in  which  they 
act,  but  who  seem  incapable  of  resisting  the  vicious  impulses 
to  which  they  are  frequently  subject. 

Nacke  69  has  suggested  the  following  provisional  classifi- 
cation of  individuals  in  whom  anomalies  of  conduct  are  pro- 
nounced:   (1)  imbeciles;    (2)  those  in  whom  the  moral  and 

88  Nacke,  P. :    Ueber  die  sogenannte  Moral  Insanity.    Wiesbaden,  1902. 


ANOMALIES    OF    CONDUCT 


125 


ethical  defects  appear  cyclically;  (3)  the  so-called  psychic 
degenerates  (in  the  sense  in  which  Magnan  employs  the 
term).  Koch70  affirms  that  the  moral  defects  are  a  sign  of 
congenital  psychopathic  degeneracy,  and  would  differentiate  an 
active  and  a  passive  form.  Brimet  recognizes  three  grades : 
moral  idiocy,  moral  imbecility,  and  moral  debility.  The  classi- 
fication, however,  is  of  relatively  less  importance  than  the 
study  of  the  symptomatology  of  the  individual  cases  and  the 
methods  to  be  adopted  in  studying  such  individuals. 

Whether  cases  of  so-called  moral  insanity  occur  without 
accompanying  intellectual  defects  is  a  much  debated  question. 
Some  observers  affirm  positively  that  cases  of  marked  defects 
in  the  ethical  and  moral  sense  are  frequently  noted  without 
demonstrable  changes  in  the  intellectual  spheres,  but  an  equal 
number  hold  a  contrary  view.  The  difficulty  arises  in  deter- 
mining what  type  of  anomaly  shall  be  classified  under  the 
head  of  an  intellectual  defect.  The  whole  controversy,  un- 
doubtedly, is  a  survival  of  the  idea  that  the  functions  of  the 
brain  were  more  or  less  isolated  and  that  one  field  might  be 
invaded  without  seriously  interfering  with  the  mental  phe- 
nomena of  another.  It  would  scarcely  exist  if  the  merely 
relative  character  of  the  phraseology  were  more  generally 
recognized  and  greater  attention  were  paid  to  the  study  of 
individual  cases.  Unquestionably,  instances  occur  in  which  the 
most  prominent  anomalies  are  in  the  emotional  reactions  and 
where  impulsivity  may  be  marked,  although  a  casual  investi- 
gation fails  to  demonstrate  the  existence  of  any  mental  im- 
pairment. Such  cases  should  be  described  sufficiently  at  length 
to  permit  whoever  reads  the  record,  and  has  sufficient  medical 
knowledge,  to  form  his  own  opinion. 

Schultze  sees  in  these  cases  no  evidence  of  general  mental 
impairment  or  feeble-mindedness,  but  attempts  to  explain  the 
phenomena  as  an  evidence  of  a  psychic  degeneracy  which 
renders  the  individual  unable  to  modify  the  automatic  ego- 
istic instincts  sufficiently  to  permit  of  the  development  of  any 

70  Die    psychopatischen    Minderwerthigkeiten.      Ravensburg,    1893. 


126  PSYCHIATRY 

altruistic  feelings.  According  to  this  view,  the  personal  in- 
terests are  so  strong  that  the  individual  is  unable  to  detach 
himself  sufficiently  from  what  immediately  concerns  himself 
to  develop  an  interest  in  any  action  with  which  he  himself  is 
not  more  or  less  directly  connected.  Such  an  hypothesis, 
however,  assumes  that  the  disturbances  of  function  must  be 
exceedingly  complex  and  accompanied  by  serious  interference 
with  the  more  complicated  forms  of  associative  memory. 
Others  find  in  the  emotional  instability  belonging  to  moral 
insanity  an  exemplification  of  the  condition  which  Wernicke 
describes  as  the  levelling  off  of  ideas.  Such  individuals  are 
more  or  less  neurotic,  exhibit  some  degree  of  unrest  as  well 
as  an  instability  of  the  emotional  life.  In  dealing  with  these 
cases,  as  in  other  forms  of  alienation,  it  must  not  be  forgotten 
that  the  original  defect  in  function,  although  sometimes  com- 
paratively slight,  may  give  rise  to  a  disturbance  which  is  to 
be  regarded  as  a  cumulative  one.  Numerous  observers  have 
demonstrated  that  a  relatively  insignificant  mental  defect  may 
be  followed  by  a  considerable  degree  of  so-called  moral  de- 
generacy. According  to  Thulie,  most  of  the  youthful  crimi- 
nals may  be  classed  among  the  "  higher  degenerates" — 
desequilibres,  or  those  described  as  being  instinctively  vicious. 


CHAPTER    IV 

THE    METHOD    OF    EXAMINATION    OF    PATIENTS,    INCLUDING 
EXAMINATION   OF   THE   CEREBROSPINAL   FLUID  1 

Whenever  the  alienist  is  called  upon  to  examine  a  patient 
he  has  a  three-fold  duty  to  perform.  In  the  first  place,  to 
determine  whether  or  not  the  individual  is  suffering  from  any 
form  of  illness.  If  this  question  is  decided  in  the  affirmative,  it 
then  becomes  necessary  to  find  out  if  possible  the  causes  which 
have  been  instrumental  in  bringing  about  the  illness  or  that 
favor  its  development  and  continuance,  as  well  as  all  other 
factors  bearing  upon  the  case,  in  order  to  determine  upon  a 
thoroughly  rational  course  of  treatment.  And,  finally,  he 
must  endeavor  to  study  every  case  that  comes  under  his  obser- 
vation with  such  care  and  accuracy  as  to  bring  to  light  any 
new  facts,  no  matter  how  trivial  they  may  at  first  sight  appear, 
that  will  lead  to  a  more  comprehensive  knowledge  of  mental 
disorders.  These  results  can  only  be  obtained  by  adopting  those 
measures  which  are  necessary  to  cultivate  and  train  the  facul- 
ties of  patient  and  accurate  observation.  Those  who  appreciate 
how  difficult  it  is  to  obtain  careful  records  in  the  cases  of  so- 
called  physical  disorders  will  appreciate  the  still  greater  difficul- 
ties which  exist  in  the  examination  of  those  who  are  afflicted 
with  alienation.  The  reasons  for  this  are,  in  the  first  place,  the 
absence  of  symptoms  which  can  in  any  sense  be  regarded  as 
pathognomonic  and  the  fact  that  the  alienist  at  present  is  deal- 
ing not  with  definite  disease  entities,  but  simply  with  groups  of 
symptoms.  One  of  the  first  difficulties  to  the  more  complete 
and  thorough  examination  of  patients  will  be  removed  when 
we  possess  a  supply  of  men  who  are  not  only  trained  in  clinical 
observation,  but  who  are  capable  of  recording  the  results  of 
their   investigations   in   simple,    direct   expression.      Unfortu- 

1  Sommer,  R. :  Lehrbuch  der  psychopatholog.  Untersuchungsme- 
thoden.  Berlin,  Wien,  1899.  Fuhrmann,  M. :  Diagnostik  u.  Geisteskrank- 
heiten.     Leipzig,  1903. 

127 


128  PSYCHIATRY 

nately,  a  great  deal  of  the  clinical  phraseology  has  a  specific 
meaning  attached  to  it,  and  clinicians  have  too  frequently 
yielded  to  the  temptation  to  abbreviate  and  to  substitute  terms 
which  have  a  relative  significance  for  simple  detailed  descrip- 
tions of  cases.  The  taking  of  records  on  especially  constructed 
charts  on  which  a  list  of  symptoms  is  printed,  the  observer  being 
expected  to  state  categorically  whether  such  a  given  symptom 
is  or  is  not  present,  is  a  most  pernicious  practice,  because,  other 
things  being  equal,  the  employment  of  such  charts  generally 
indicates  that  those  who  are  to  take  the  clinical  histories  have 
not  been  sufficiently  drilled  in  the  methodical  examination  of 
patients.  Psychiatry  has  passed  through  the  era  when  it  was  con- 
sidered sufficient  to  study  cases  en  masse,  and  everything  should 
be  done  in  order  to  encourage  the  careful,  detailed  observation 
of  every  individual  patient.  During  the  conduct  of  the  clinical 
examination  it  should  always  be  borne  in  mind  that  the  whole 
personality  of  the  individual  is  more  or  less  involved.  Mental 
disorders  are  not  merely  brain  diseases  with  localized  disturb- 
ances of  function,  and  we  must  be  continually  on  our  guard  lest 
we  gradually  fall  into  the  habit  of  seizing  upon  certain  symp- 
toms or  certain  phases  of  the  disease,  while  others  are  ignored. 
In  cases  of  mental  disorder  more  than  in  others  there  always 
exists  a  strong  tendency,  which  must  be  continually  combated, 
to  make  the  clinical  picture  fit  some  arbitrarily  constructed 
frame. 

Anamnesis. — Family  History. — Only  very  rarely  is  it 
possible  to  obtain  from  the  family  history  sufficient  data  to 
justify  any  deductions  that  have  any  immediate  bearing  upon 
the  problems  of  heredity.  Nevertheless,  in  the  majority  of 
cases  we  shall  be  able  to  gain  from  such  an  inquiry  a  fairly 
good  idea  with  regard  to  the  environment  in  which  the  indi- 
vidual has  been  living.  If  alienation  is  found  to  have  existed 
in  a  patient's  family,  we  should  find  out  whether  it  was  a 
progenitor,  a  descendant,  or  a  collateral  that  was  affected,  what 
was  the  probable  cause  of  the  trouble,  and  the  age  and  environ- 
ment of  the  individual  in  whom  the  disorder  made  its  appear- 
ance. If  possible,  a  sufficient  number  of  facts  should  be  recorded 


EXAMINATION    OF    PATIENTS 


129 


to  enable  any  one  who  subsequently  reads  the  history  to  form 
his  own  opinion  as  to  the  medical  character  of  the  malady.  If 
the  occurrence  of  pronounced  mental  alienation  is  not  admitted, 
we  should  search  for  any  symptoms  of  mental  deterioration  or 
degeneracy — suicide,  alcoholism,  eccentricities  of  character,  and 
the  like — that  would  indicate  the  existence  of  functional  dis- 
orders. Some  light  may  also  be  obtained  from  definite  data 
concerning  the  causes  of  death  in  the  cases  of  various  members 
of  the  family — apoplexy,  convulsions,  tuberculosis,  Bright's 
disease,  etc. 

Regarding  the  parents  of  the  individual,  it  is  important  to 
note  whether  they  were  blood  relatives;  whether  one  or  both 
were  alcoholics ;  whether  there  was  any  marked  discrepancy  in 
their  ages,  and  so  on.  The  question  of  lues  in  the  parents  must 
always  be  kept  in  mind,  but  of  necessity,  although  searching,  our 
inquiries  must  be  made  cautiously.  When  direct  questions  can 
not  be  put,  or  when  put  can  not  be  answered,  we  should  try  to 
find  out  whether  there  has  been  a  history  of  skin  eruptions,  sore 
throat,  falling  out  of  the  hair,  rheumatic  pains,  bone  diseases, 
frequent  miscarriages  on  the  part  of  the  mother,  etc.,  as  such 
points,  even  when  not  conclusive,  have  always  a  certain  signifi- 
cance, the  importance  of  which  should  be  carefully  weighed. 
Information  regarding  the  social  and  intellectual  status  of  the 
family  and  whether  there  have  been  any  sudden  changes  in 
these  conditions  is  also  of  importance.  As  has  already  been 
pointed  out,  a  sudden  change  in  the  social  status  of  a  family, 
such  as  that  following  the  sudden  acquirement  of  great  wealth, 
or  the  sudden  transformation  that  sometimes  follows  the  relin- 
quishing of  manual  for  intellectual  pursuits,  is  often,  particu- 
larly in  this  country,  accompanied  by  the  appearance  of  nervous 
or  mental  disease. 

Personal  History:  Infancy  and  Childhood. — This  should 
begin  with  questions  regarding  the  condition  of  the  mother 
during  pregnancy,  especially,  did  she  suffer  from  nephritis,  any 
acute  infectious  disease,  trauma,  mental  shock,  or  sudden  change 
in  her  mode  of  life  ?  Following  this  an  attempt  should  be  made 
to  ascertain  the  conditions  under  which  birth  occurred — whether 

9 


130  PSYCHIATRY 

at  full  term  or  prematurely,  whether  it  was  normal,  protracted, 
or  instrumental,  and  the  apparent  effects  upon  the  child.  What 
infectious  diseases  or  trauma  occurred  during  the  early  years 
of  infancy?  Such  incidents  should  be  noted,  and  we  should 
attempt  to  determine  whether  or  no  there  was  any  subsequent 
impairment  in  the  mental  or  physical  development  of  the  child. 
If  a  history  of  convulsions  be  obtained,  their  probable  cause, 
duration,  and  frequency  should  be  recorded  as  well  as  the  na- 
ture of  any  paralyses  that  may  have  followed.  At  what  age 
teething  began  and  whether  the  process  was  accompanied  by 
any  unfavorable  signs ;  at  what  age  the  child  learned  to  walk 
or  speak;  the  severity,  duration,  and  sequelae  of  the  so-called 
children's  diseases,  should  all  be  made  the  subject  of  particular 
inquiry.  The  signs  of  rickets  should  be  carefully  distinguished, 
and  a  full  note  be  made,  if  possible,  upon  the  mental  traits  of 
the  child — as  to  its  impressionability,  nervousness,  fears,  way- 
wardness, temper,  and  whether  it  had  to  be  treated  differently 
from  other  children.  The  age  at  which  schooling  began  and 
the  progress  made  should  be  stated. 

Puberty.- — The  mental  and  physical  state  of  the  patient 
prior  to  the  onset  of  puberty  having  been  recorded  with  as  great 
detail  as  possible,  a  note  of  contrast  as  to  the  changes  that  may 
have  taken  place  at  this  critical  epoch  should  follow.  Was  the 
mental  and  physical  development  precocious,  delayed,  or  in  any 
way  abnormal?  Particularly  important  at  this  stage  are  the 
eccentricities  of  character.  In  girls  the  age  at  which  the  menses 
appeared  should  be  noted,  as  well  as  such  attendant  circum- 
stances as  anaemia,  nervousness,  pain,  signs  of  mental  depres- 
sion, hypochondriasis,  and  an  excessive  exhibition  of  religious 
conviction. 

Continuing,  the  development  of  the  individual,  both  physi- 
cal and  mental,  should  be  traced,  and  any  instances  of  impair- 
ment of  the  physical  vigor  should  be  cited,  particularly  the 
occurrence  of  an  attack  of  any  infectious  disease- — such  as 
typhoid  fever,  pneumonia,  malaria,  meningitis,  gastro-intestinal 
disturbances, — as  well  as  of  any  constitutional  diseases — 
syphilis,  tuberculosis, — and  any  of  the  various  functional  dis- 


EXAMINATION    OF    PATIENTS 


131 


orders — hysteria,  hypochondriasis,  epilepsy.  What  were  ap- 
parently the  immediate  and  remote  effects  upon  the  individual? 
In  febrile  disorders  the  occurrence  of  delirium  or  convulsions 
or  mental  disorders  may  have  an  important  bearing  on  the  sub- 
sequent history.  If  trauma  or  an  attack  of  some  disease  is 
recorded,  the  facts  should  be  given  with  sufficient  detail  in  the 
history  to  enable  a  reader  to  determine  for  himself  whether  this 
factor  is  to  be  considered  of  importance  in  relation  to  subse- 
quent events  in  the  life  of  the  individual.  Personal  idiosyn- 
crasies, the  evidences  of  a  neuropathic  constitution, — such  as 
marked  fluctuations  in  the  emotional  life,  a  tendency  towards 
excessive  blushing,  palpitation,  attacks  of  nervousness  with 
apprehension  and  fear,  excessive  morbidity,  intolerance  for 
alcoholic  beverages,  mental  irritability*,  as  well  as  an  inability 
to  bear  pain  or  mental  distress, — should  be  recorded. 

The  emotional  life  of  the  individual  should  be  carefully 
investigated  and  the  attempt  made  to  determine  whether  fluc- 
tuations in  it  apparently  became  more  or  less  marked  after 
puberty  or  whether  a  marked  indifference  to  higher  interests 
and  a  loss  of  an  altruistic  spirit  developed.  AY  as  there  any 
tendency  shown  towards  the  formation  of  marked  antipathies 
either  for  persons  or  ob j  ects  ?  Was  such  a  condition  dependent 
upon  the  result  of  chance  impulses  or  did  it  develop  slowly 
from  what  were  first  groundless  and  fleeting  suspicions  but 
later  were  transformed  into  definitely  crystallized  and  fixed 
ideas  ?  The  individual's  general  view  of  life,  characterized  by 
excessive  optimism  or  pessimism,  and  any  apparent  lack  of 
ability  to  adapt  himself  to  his  surroundings  should  be  explicitiy 
described.  As  the  individual  became  older  the  cropping  up 
of  personal  eccentricities,  an  exaggerated  egotism,  and  an 
abnormal  tenacity  of  personal  views  on  social,  political,  or 
religious  questions,  the  quality  of  temperament  indicative  of  a 
phlegmatic,  apathetic,  excessively  ambitious,  or  jealous  nature, 
deserve  attention.  An  attempt  should  be  made  to  determine 
whether  all  the  faculties  were  developed  harmoniously  or 
whether  intellectual  progress  took  place  along  certain  limited 
lines.     If  the  individual  showed  remarkable  attainments  in  one 


132  PSYCHIATRY 

direction,  were  there  corresponding  defects  in  others?  Of 
what  nature  were  his  social  relationships,  particularly  regard- 
ing the  members  of  the  immediate  family  ?  In  the  examination 
of  women  particular  attention  should  be  paid  to  the  slight 
anomalies  of  the  mental  functions  that  may  be  associated  with 
the  menses.  Was  there  an  increase  of  nervousness,  or  any 
degree  of  mental  depression?  The  same  points  are  of  im- 
portance in  connection  with  pregnancy  and  the  climacterium. 
At  what  period  did  the  mental  anomalies  first  make  their 
appearance,  and  what  was  their  character? 

Present  Illness. — Causes. — When  possible  it  is  desirable 
to  establish  a  more  or  less  definite  date  at  which  the  patient  was 
last  said  to  have  been  in  "  good  health,"  and  then  to  trace,  as 
logically  and  connectedly  as  possible,  the  development  of  the 
symptoms  from  that  time  on  until  the  moment  that  he  first  came 
under  observation.  From  the  information  obtained  it  will  be 
noted  whether  the  present  illness  is  the  first  attack  of  alienation 
or  represents  merely  a  recurrence  of  symptoms  that  have  been 
noted  in  other  periods  of  life. 

The  primary  operative  causes  must  be  sought  for  and  the 
character  of  the  symptoms,  their  course  and  development,  de- 
termined, as  well  as  the  sudden  or  gradual  appearance  of  the 
alienation.  All  the  physical  ailments  should  be  carefully  noted 
in  as  minute  detail  as  if  an  examination  were  being  made  in  a 
case  of  typhoid  fever  or  pneumonia,  after  which  particular 
attention  should  be  paid  to  all  the  mental  symptoms,  anomalies 
of  memory,  impaired  intellectual  capacity,  a  diminished  or  ex- 
cessive feeling  of  fatigue,  fluctuations  in  the  emotional  life, 
changes  of  character,  moral  defects,  psychic  painful  states  or 
depression,  fear,  intellectual  and  physical  disquietude,  pes- 
simism, excessive  optimism,  reticence  or  loquaciousness,  dream 
states,  the  "  wandering  manias,"  any  tendency  towards  extrava- 
gance and  a  reckless  plunging  into  new  undertakings  without 
waiting  to  count  the  cost,  and  any  other  evidences  of  mental 
peculiarities.  The  appearance  of  imperative  processes,  halluci- 
nations, delusions,  ideas  of  reference,  insane  ideas  and  their 
apparent  influence  upon  the  conduct  of  the  individual,  should  be 


EXAMINATION    OF    PATIENTS 


133 


recorded.  The  apparent  relationships  between  the  mental  and 
physical  disturbances  should  be  sought  for  and  noted.  What 
effect  did  these  anomalies  in  mental  activity  have  upon  sleep, 
upon  the  weight  of  the  individual,  upon  the  secretory  or  the 
excretory  functions?  When  a  full  history  of  the  individual 
symptoms  has  been  obtained  the  attempt  must  be  made  to  show 
whether  the  course  of  the  malady  has  been  continuous,  inter- 
mittent, or  remittent,  and  if  the  relation  of  the  various  symp- 
toms to  each  other  has  been  constant  or  changing. 

Status  Prcesens. — When  the  individual  is  not  greatly  ex- 
cited the  physical  examination  is  usually  undertaken  as  soon  as 
the  history  has  been  completed.  But  when  the  motor  restless- 
ness is  very  great,  or  if  for  some  other  reason  a  thorough  exami- 
nation is  contraindicated  at  the  time  of  admission,  it  is  always 
not  only  possible  but  most  important  to  make  a  careful  note 
upon  the  mental  state  of  the  patient  according  to  the  methods 
to  be  referred  to  presently.  The  physical  examination  should 
be  as  complete  as  that  made  upon  patients  in  the  best  general 
hospitals,  into  the  details  of  which  it  is  not  necessary  to  go  at 
present.  In  regard  to  the  observation  of  the  physical  symptoms 
the  following  points  should  be  noted,  although  no  hard  and  fast 
scheme  should  be  adopted  (vide  Lehrbuch  der  Psychiatrie,  v. 
Krafft-Ebing,  Wien,  1904,  p.  243).  The  measurement  of  the 
skull  along  a  line  just  above  the  external  occipital  protuberance 
and  glabella  should  always  be  taken.  Although  the  normal  for 
men  is  55  centimetres,  and  for  women  53  centimetres,  variations 
within  certain  limits  are  not  uncommon,  and  for  practical  pur- 
poses all  skulls  whose  circumference  does  not  fall  below  48  or 
exceed  56  may  be  considered  normal.  The  ordinary  distance 
between  the  extreme  lateral  points  of  the  skull  measured  by 
means  of  the  calipers  is  between  14  and  15  centimetres.  Other 
signs  of  physical  degeneracy  are  to  be  looked  for  in  connection 
with  the 

(1)  Eyes:  Rhombo-,  lepto-,  and  clino-cephalus.  Retinitis 
pigmentosa,  coloboma  iridis,  albinism,  unequal  pigmentation 
of  the  iris,  congenital  strabismus. 

(2)  Nose:  Any  unusual  prominence  or  malformation  of 


134  PSYCHIATRY 

the  nose;    e.g.,  the  thickening  of  the  lateral  roots  noted  in 
myxcedema  and  cretinism. 

(3)  Ears:  Morel's  ear,  smooth  helix ;  the  Darwinian  ear, 
satyr-shaped  with  prominent  tubercles;  Wildermuth's  ear,  in 
which  the  antihelix  is  proportionately  much  larger  than  the 
helix. 

(4)  Teeth:  Total  or  partial  defect  in  secondary  dentition; 
abnormal  position  of  the  teeth. 

(5)  Mouth  and  gums:  Excessively  small  or  large  gums, 
as  well  as  anomalies  of  the  hard  and  soft  palate. 

(6)  Skeleton  and  extremities:  Signs  of  dwarfism,  club- 
foot, club-hand,  unequal  development  of  the  hand,  supernumer- 
ary hand,  unequal  development  of  the  fingers  and  toes. 

(7)  Genitalia:  Cryptorchia,  epispadias,  hypospadias  or 
hermaphrodism,  uterus  infantilis,  uterus  bicornis,  phimosis  or 
lengthening  and  hypertrophy  of  the  fore-skin. 

(8)  Hair:  Sparsity  or  occurrence  of  hair  in  abnormal 
locations. 

After  this  follows  the  examination  of  the  higher  sensory 
organs,  the  eye  and  ear,  for  which  the  ophthalmoscope  and 
otoscope  render  important  aid. 

Sensibility:  Hyperesthesias,  anaesthesias,  and  paresthe- 
sias, neuralgias,  reactions  to  the  sesthesiometer  needle,  electrical 
current,  heat  and  cold. 

Cutaneous  and  deep  reflexes. 

Motor  functions:  Facial  innervation,  mydriasis,  myosis, 
unevenness  of  the  pupils,  reaction  of  the  iris  to  atropin  or 
cocain,  nystagmus,  strabismus,  paralysis  of  the  eye  muscles, 
ptosis,  speech,  aphasia,  ataxia,  glossoplegia,  tremor,  paresis,  dis- 
turbances of  sphincters,  catalepsy,  and  muscular  contractions. 

Secretory  'functions:  Salivation,  excessive  sweating,  uni- 
lateral or  general.    Examination  of  urine. 

Trophic  disturbances  of  the  skin:   Perforating  ulcers,  etc. 

Testing  the  Mental  State. — The  method  of  examination 
of  the  mental  faculties  that  should  be  employed  in  whole  or  in 
part  as  soon  as  the  patient  enters  the  hospital  will  now  be  de- 
scribed.    In  a  private  household  it  is  often  impossible  to  con- 


EXAMINATION    OF    PATIENTS 


135 


duct  an  examination  which  is  thorough  and  satisfactory,  and 
even  in  institutions  the  method  employed  must  be  frequently 
modified  to  meet  the  exigencies  of  the  case. 

As  soon  as  the  patient  is  brought  to  the  hospital  he  should 
at  once  be  taken  in  charge  by  one  of  the  resident  physicians, 
and  as  complete  a  record  as  possible  of  all  objective  symptoms 
should  be  made  within  an  hour  or  two  after  his  admission. 
Unfortunately,  a  failure  to  appreciate  the  necessity  of  recording 
the  symptoms  as  they  arise  often  leaves  us  with  a  report  that 
the  patient  was  in  too  excited  a  condition  to  be  examined,  and 
as  a  consequence  no  notes  are  made  upon  the  case  until  the 
individual  has  become  somewhat  accustomed  to  his  surround- 
ings and  has  quieted  down.  When  such  a  course  is  followed 
many  valuable  details  may  be  overlooked  and  forgotten,  and 
it  must  be  insisted  that  in  many  instances  the  manner  in  which 
the  individual  reacts  to  his  new  environment — especially  the 
presence  or  absence  of  any  attempt  to  try  to  adjust  his  conduct 
so  as  to  meet  the  new  conditions — is  of  vital  importance.  To 
facilitate  the  description  of  the  examination  the  patients  will 
be  divided  into  two  main  classes, —  (A)  those  who  can  not  or 
will  not  respond  to  questions;  (B)  those  who  are  able  and 
willing  to  do  so. 

(A)  In  dream-like  and  stuporous  states  the  examiner 
should  make  an  accurate  record  of  the  effect  produced  by  ex- 
ternal stimulation.  Although  consciousness  may  be  so  dull 
that  all  evidences  of  mentality  are  absent,  if  the  individual  is 
pricked  with  a  needle  or  touched  with  a  hot  or  cold  object,  a 
visible  reaction,  such  as  a  slight  change  of  position  or  of  the 
facial  expression,  an  increase  of  the  rapidity  of  the  pulse  or 
respiration,  not  infrequently  follows. 

In  many  instances  the  failure  to  respond  to  questions  is 
due  to  excitement.  This  is  true  for  the  various  manic  states 
such  as  occur  in  alcoholism,  manic-depressive  insanity,  dementia 
prsecox,  epilepsy,  and  a  variety  of  other  conditions.  When  such 
is  the  case  the  examiner  should  describe  as  accurately  but  as 
tersely  as  possible  the  general  appearance  and  conduct  of  the 
individual.      The   effects   of   external   stimulation   should   be 


136  PSYCHIATRY 

noted :  whether  it  tends  or  does  not  tend  to  increase  the  excite- 
ment, or  whether  the  patient  is  so  absorbed  in  his  own  acts  and 
thoughts  that  he  is  utterly  oblivious  to  his  surroundings.  Not  in- 
frequently at  first  sight  an  individual  fails  to  respond  to  external 
stimuli,  and  yet  on  a  more  careful  examination  it  will  be  noticed 
that  when  he  is  spoken  to  or  stimulated  in  any  way  there  is  an 
increase  in  the  excitement,  although  there  may  be  no  evidence 
of  distractibility.  In  such  instances  the  individual,  if  he  be 
talking  or  shouting,  when  addressed  only  talks  and  shouts  the 
louder,  and  the  intensity  of  the  general  motor  restlessness  is 
increased.  In  some  stages  of  catatonic  excitement,  however, 
although  the  individual  may  be  exceedingly  uproarious  and 
boisterous,  external  stimulation  seems  to  have  little,  if  any, 
effect  in  increasing  the  intensity  of  the  reactions.  In  noting 
the  general  appearance  and  character  of  the  actions  it  is  very 
important  to  determine  whether  there  is  any  correspondence 
between  the  ideas  which  flash  through  the  patient's  mind  and 
the  visible  facial,  gestural,  or  postural  reactions.  Thus,  in  an 
individual  who  is  aggressive,  uproarious,  or  furious,  does  the 
facial  expression  or  what  the  patient  says  in  any  measure  corre- 
spond with  the  visible  reaction,  or  does  each  act  seem  to  be  the 
result  of  purely  dissociated  and  fleeting  impulses?  In  this,  as 
in  all  other  descriptions,  the  use  of  technical  terms  should  be 
scrupulously  avoided  in  the  main  text,  although  they  may  be 
retained  as  marginal  notes  or  in  a  summary  of  a  detailed 
description. 

If  the  individual  is  able  to  utter  intelligent  sounds,  the 
character  of  the  speech  should  be  carefully  noted :  (a)  Its  neu- 
rological features.  Is  there  a  tendency  towards  the  slurring  of 
syllables,  any  dropping  of  words  or  scanning?  (b)  The  con- 
tent of  what  is  said  may  either  be  taken  down  in  shorthand  by  a 
stenographer  or,  better  yet,  by  means  of  a  large  phonograph, 
from  which  transcription  can  be  made  later.  In  some  in- 
stances, however,  the  excitement  of  the  individual  is  so  great 
that  by  neither  method  is  it  possible  to  get  a  full  report  of  what 
is  said.  If  the  speech  is  incoherent,  particular  attention  should 
be  paid  to  the  expressions  used,  to  determine  ( 1 )  whether  cer- 


EXAMINATION    OF    PATIENTS  137 

tain  words  or  syllables  are  constantly  repeated  (stereotyped 
iteration)  ;  (2)  whether  the  patient  uses  a  great  variety  of 
new  words  (neologismus)  or  whether  there  is  an  evident  in- 
clination to  resort  to  diminutives,  doubling  of  the  words,  onoma- 
topoietic  expressions  and  disfigurement  of  speech.2  Sometimes 
when  the  stereotypy  of  speech  is  marked  many  words  begin 
with  a  prolonged  hissing  sound,  as  if  the  patient  were  about  to 
stammer,  and  the  word  is  then  pronounced  with  a  marked  ex- 
plosiveness.  (3)  Notes  should  be  made  upon  the  apparent  rela- 
tion of  the  words  used  to  the  ideas  expressed.  Patients 
afflicted  with  dementia  praecox  will  frequently  give  utterance 
to  several  sentences  grammatically  formed  and  logically  ex- 
pressed, and  then  several  words  which  bear  no  reference  to 
what  has  preceded  are  suddenly  interjected.  The  rhetoric  should 
be  described,  especially  if  the  patient  has  any  tendency  to  express 
himself  in  a  bombastic  or  egotistical  manner.  In  excited 
patients  it  is  important  to  determine  whether  the  flight  of  ideas 
(Ideenflucht,  Fuite  des  idees)  is  present,  in  which  case  the  asso- 
ciation of  ideas  is  clearly  merely  superficial,  indicating  that  the 
patient  has  little  selective  or  critical  power  left,  and  the  flow  of 
words  has  no  definite  end  in  view,  being  merely  the  result  of 
hap-hazard  impulses  due  to  internal  or  external  stimulation. 
The  words  used  apparently  suggest  sound  associations  or 
alliterations,  and  when  the  true  manic  condition  exists  the  ideas 
expressed  indicate  exhilaration  and  exaltation. 

As  regards  the  content  of  what  is  said,  it  is  important  to 
note  (1)  whether  there  is  any  suggestion  made  as  to  the  ex- 
istence of  hallucinations  or  insane  ideas;  (2)  any  tendency  to 
confabulate  or  indulge  in  pseudoreminiscences  (pseudologia 
fantastica). 

It  is  further  important  to  determine  whether  the  logor- 
rhcea  is  affected  by  external  sensory  stimuli  or  whether  it  is 
merely  the  product  of  ideas  which  keep  flashing  through  the 
patient's  mind.    In  the  former  case  it  will  be  noted  that  sensory 


3  Sante  de  Sanctis.     Intorno  alia  psicopatologia  dei  neologismi.     An- 
nali  di  nevrologia,  xx,  p.  597. 


138  PSYCHIATRY 

impressions,  visual,  auditory,  or  others,  immediately  deflect  or 
disturb  the  patient's  attention.  When  the  excitement  is  greatest 
this  effect  may  only  be  manifested  by  an  increase  in  the  intensity 
of  the  speech  reaction  without  any  deviation  in  the  flow  of  ideas. 
In  other  cases,  however,  the  effect  of  the  incident  visual  and 
auditory  stimuli  becomes  at  once  apparent,  since  the  patient 
refers  directly  or  indirectly  to  what  has  been  heard  or  seen. 
In  many  instances  the  attention  is  so  riveted  upon  the  delusions 
or  hallucinations  of  which  he  is  the  subject  that  the  patient  is 
unable  to  respond  to  questions.  In  many  cases  the  effects  that 
these  phenomena  have  are  immediately  reflected  in  the  physiog- 
nomy or  general  action  of  the  patient.  Hence  an  accurate 
description  of  the  facial  expression  is  of  great  importance.  Is 
the  individual  sad,  depressed,  and,  if  so,  is  it  shown  by  the 
wrinkling  of  the  forehead,  the  glassy  appearance  of  the  eyes,  the 
absence  of  tears,  the  drooping  of  the  corners  of  the  mouth  ?  Or 
if  anxiety,  apprehensiveness,  mistrust  or  actual  suspicion,  list- 
lessness  and  apathy,  exhilaration  and  exaltation,  pride  or  arro- 
gance, are  present,  what  objective  expressions  of  these  are 
reflected  in  the  facial  reactions  or  general  attitude  of  the 
individual?  In  addition  to  the  physiognomy  and  actions  of 
the  patient  attention  should  be  paid  to  the  character  of  his  dress 
or  toilet,  both  of  which  frequently  throw  some  light  upon  the 
mental  state,  the  maniacal  patient  frequently  exhibiting  a  ten- 
dency to  deck  himself  in  gaudy  colors,  to  exhibit  theatrical 
mannerisms  and  eccentricities  in  dress,  whereas  other  indi- 
viduals are  unmindful  and  neglectful  of  their  personal  attire  as 
well  as  their  individual  needs.  The  mannerisms  of  the  indi- 
vidual are  important,  and  any  tendency  towards  the  repetition 
of  stereotyped  movements  or  phrases  should  at  once  be  noted. 
If  the  patient  shows  a  tendency  to  strike  dramatic  attitudes  or  to 
pose,  the  attempt  should  at  once  be  made  to  ascertain  whether 
there  is  a  definite  motive  in  consciousness  for  such  an  act,  or 
whether  it  is  merely  the  result  of  chance  impulse  or  stereotyped 
repetitions. 

The  occurrence  of  negativism  is  an  important  symptom. 
When  well  marked  it  may  be  easily  recognized,  but  it  is  often 


EXAMINATION    OF    PATIENTS  1 39 

very  difficult  to  positively  affirm  that  the  individual  is  nega- 
tivistic  and  not  actuated  by  the  presence  of  fallacious  sense  per- 
ceptions or  insane  ideas.  The  negativistic  patient  does  just  the 
opposite  of  what  a  rational  individual  would  do  under  the 
same  circumstances.  The  appearance  of  an  emotional  storm 
would  indicate  that  the  conduct  is  actuated  by  the  appearance 
in  consciousness  of  some  idea  and  that  the  case  is  not  one  of 
pure  negativism.  In  extreme  cases  the  patient  refuses  food, 
and  any  form  of  external  stimulation  seems  to  start  up  reflexly 
this  silly,  unmotived  resistance.  Patients  in  this  condition 
seldom,  if  ever,  speak,  or  their  speech  is  monosyllabic  or  limited 
to  a  few  disconnected  words.  If  an  attempt  is  made  to  flex  or 
extend  a  limb,  to  turn  the  head  or  open  the  eyes,  the  patient  at 
once  becomes  resistive.  Where  the  symptoms  are  not  so  in- 
tense, it  will  be  noticed  that  a  request  to  raise  an  arm  or  a  leg 
or  to  close  one  eye  may  result  in  some  movement,  but  generally 
not  the  one  asked  for  (parapraxia).  The  so-called  flexibilitas 
cerea  is  seen  in  a  variety  of  conditions. 

If  automatism  is  present,  when  passive  movements  are 
made  as  soon  as  the  examiner  relaxes  his  hold  of  the  patient's 
limb  the  movements  are  continued  automatically.  To  be  dis- 
tinguished from  simple  automatism  is  command  automatism, 
in  which  a  patient  is  compelled  to  execute  unpleasant  or  un- 
welcome movements  or  is  prevented  from  making  normal  de- 
fensive movements  when  variously  threatened.  This  condition 
is  probably  the  result  of  a  paresis  of  volition  occurring  largely 
in  catatonics.  These  conditions  are  frequently  noted  in  cata- 
tonic as  well  as  in  hypnotic  dream  states.  The  general  appear- 
ance of  patients  who  are  in  this  cataleptic  condition  is  more  or 
less  characteristic  and  should  be  described.  The  face  is  ex- 
pressionless, the  eyes  have  a  vacant  stare.  Mutism  exists  and 
the  volitional  movements  are  reduced  to  a  minimum.  The 
tendency  for  movements,  when  once  initiated,  to  persevere  may 
be  noted  in  cases  of  catatonia.  If  the  patient  is  asked  to  touch 
the  tip  of  his  nose  with  the  finger,  several  seconds  may  elapse 
before  the  request  is  complied  with,  but  when  the  movement 
has  once  been  begun  it  continues  whenever  the  patient  is  stimu- 


140  PSYCHIATRY 

lated,  no  matter  if  a  totally  different  request  has  been  made. 
The  stereotyped  automatic  movements  of  the  catatonic  indi- 
vidual are  highly  characteristic  and  essentially  different  from 
those  of  the  patients  who  are  actuated  by  definite  ideas.  Some 
catatonic  patients  will  never  enter  a  room  without  walking-  along 
one  line  in  the  carpet,  or  will  sit  and  play  solitaire  by  the  hour  in 
an  automatic  way,  making  the  same  mistakes  and  always  going 
through  the  same  movements.  The  mannerisms  are  particu- 
larly noticeable  when  such  individuals  feed  themselves  or  make 
the  attempt  to  dress.  Some  patients  will  sit  by  the  hour  turning 
their  heads  from  side  to  side  in  a  rhythmic,  stereotyped  manner. 
Even  the  movements  of  respiration  seem  to  be  affected,  and  at 
intervals  of  a  few  seconds  the  patient  will  take  a  long  breath 
followed  by  sighing  expiration.  Sometimes  echopraxia  corre- 
sponding with  echolalia  occurs. 

(B)  When  the  individual  is  both  able  and  willing  to  reply 
to  questions,  after  the  objective  symptoms  which  are  apparent 
on  superficial  examination  have  been  noted,  a  more  detailed 
examination  of  the  mental  condition  is  made.  The  manner  in 
which  the  patient  replies  to  questions  should  be  described.  In 
the  first  place,  a  considerable  interval  may  elapse  from  the  time 
the  question  is  put  before  any  visible  reaction  signifies  that  the 
sense  of  the  interrogation  has  been  apprehended.  Such  a  delay 
frequently  occurs  in  states  of  depression,  whereas  in  excitement 
the  reply  is  given  with  lightning-like  rapidity.  Sometimes,  how- 
ever, although  the  sense  of  the  question  seems  to  be  quickly 
apprehended,  there  may  still  be  a  pause — the  result  of  delayed 
reaction  or  psychomotor  retardation.  If  the  patient  is  under 
the  influence  of  an  hallucination  or  an  insane  idea,  the  delay 
may  be  purposeful.  In  many  instances  the  patient  must  be  very 
carefully  studied  and  all  the  evidence  carefully  weighed  before 
it  is  possible  to  determine  with  which  one  of  the  two  conditions 
we  are  dealing.  The  content  of  what  is  said  should  be  recorded 
as  carefully  as  possible,  and  we  should  note  whether  or  not  the 
patient  has  a  tendency  to  be  garrulous,  to  enter  into  great  detail 
in  all  his  statements  (circumstantiality),  and  whether  or  not 
any  marked  degree  of  irrelevancy  is  present. 


EXAMINATION    OF    PATIENTS  I4I 

The  emotional  state,  as  reflected  in  the  facial  expression  as 
well  as  in  other  reactions,  may  be  an  important  feature  in  the 
case.  The  examiner  should  describe  the  facial  expression, 
whether  it  is  apathetic,  depressed,  elated,  etc.,  and  then  an  at- 
tempt should  be  made  to  determine  if  the  visible  reactions  are  or 
are  not  in  accord  with  the  idea  that  occupies  the  patient's  field  of 
consciousness.  In  stages  of  manic  excitement  the  patient  may  be 
angry,  depressed,  or  joyful,  and  at  once  gives  evidence  of  what 
is  passing  before  his  mind.  But  it  is  eminently  characteristic  of 
certain  conditions  that  a  marked  dissociation  between  the  idea 
(noopsyche)  and  the  visible  reaction  (thymopsyche)  exists. 

Many  of  the  psychological  tests  suggested  are  too  com- 
plicated to  be  of  value  in  the  clinic.  As  a  rule,  we  begin  with  a 
note  upon  the  patient's  attention.  Is  it  easily  gained  and,  if  so, 
is  it  well  maintained,  or  does  it  easily  lapse  and  is  there  a  great 
degree  of  distractibility?  If  distractibility  is  present,  it  is  well 
to  note  whether  it  is  produced  by  all  incident  stimuli  or  only 
follows  certain  kinds.  A  very  good  simple  clinical  test  for  the 
attention  of  educated  individuals  is  the  so-called  "  one-hundred 
test."  The  individual  who  is  being  examined  is  asked  to  sub- 
tract six  or  seven  from  one  hundred  and  to  continue  the  sub- 
traction down  to  zero.  Evidences  of  mental  fatigue  and  dis- 
tractibility can  often  be  easily  demonstrated  by  this  simple 
method.  The  functions  of  associative  memory  should  then  be 
tested.  This  includes  the  power  of  picking  up  and  retaining 
impressions  and  the  faculty  of  re-collecting  and  redeveloping 
memory  pictures  referring  to  a  more  remote  period  in  the  past. 
An  excellent  idea  of  the  power  of  associative  memory  is  ob- 
tained by  asking  the  patient  to  give  an  account  of  his  present 
illness  and  of  the  events  in  his  past  life  which  have  any  bearing 
upon  the  condition.  The  tendency  to  indulge  in  pseudoreminis- 
cences  or  to  confabulate  may  become  noticeable.  In  many 
cases,  although  there  is  no  positive  defect  in  memory,  a  note 
should  be  made  as  to  whether  the  patient  does  or  does  not  com- 
plain of  a  subjective  defect  in  recollection.  In  connection  with 
memory  it  is  important  to  note  whether  the  orientation  of  the 
patient  is  impaired  either  in  its  spatial  or  time  relations.     Such 


142  PSYCHIATRY 

defects,  as  a  rule,  quickly  become  apparent  when  the  individual 
is  asked  a  number  of  simple  questions.  How  long  have  you 
been  in  the  hospital  ?  How  long  have  you  been  ill  ?  Where  is 
the  hospital  situated?  Where  is  your  home?  Closely  associ- 
ated with  the  sense  of  orientation  is  the  so-called  sense  of 
recognition,  disturbances  of  which  are  not  infrequently  noted. 
These  may  be  transitory,  as  in  conditions  of  neurasthenia  and 
epilepsy,  or  may  be  more  permanent  and  occur  in  the  states  of 
excitement  in  certain  psychoses.  The  disorientation  of  the 
patient  may  still  further  be  conditioned  by  the  occurrence  of 
either  hallucinations  or  insane  ideas  and  affect  -either  the 
somatopsychic,  autopsychic,  or  allopsychic  field  of  conscious- 
ness. 

The  power  of  the  individual  to  associate  ideas  may  be 
tested,  either  in  reply  to  questions  or  by  his  voluntary  conversa- 
tion as  well  as  by  the  writing  obtained.  Simple  tests  may  also 
be  used,  such  a  one,  for  example,  as  that  proposed  by  Fuhr- 
mann.  One  hundred  test  words  are  printed  on  a  slip  and  the 
patient  is  told,  as  soon  as  a  word  is  called  off  to  him,  to  describe 
the  quality  of  the  object  named.  The  length  of  time  that  elapses 
between  the  calling  off  of  the  word  and  the  reply  is  noted.  In 
intelligent  individuals  it  is  estimated  that  from  95  to  100  per 
cent,  of  the  associations  are  correctly  given.  But  when  there 
is  a  marked  diminution  in  the  intelligence  or  when  the  reactions 
are  greatly  impaired  the  number  falls  below  70  per  cent. ;  and 
when  it  is  as  low  as  60  per  cent,  there  can  be  no  doubt  that 
a  pathological  condition  exists.  The  quickness  of  the  reaction 
may  be  tested  in  a  variety  of  different  ways,  by  the  chromo- 
scope,  for  instance,  although  for  all  practical  purposes  the 
various  forms  of  apparatus,  all  of  which  are  more  or  less  com- 
plicated, have  little  advantage  over  the  simpler  clinical  tests. 

The  examiner  should  attempt  to  ascertain  whether  the 
disturbances  of  the  association  are  merely  of  a  negative  char- 
acter or  due  to  the  cropping  up  in  consciousness  of  autochtho- 
nous ideas  which  are  recognized  by  the  individual  as  having 
developed  in  some  strange  and  unaccountable  fashion.  In 
ideas  of  reference  the  individual  often  attributes  to  his  own 


EXAMINATION    OF    PATIENTS  143 

words  or  actions  as  well  as  to  those  of  others  an  exaggerated 
importance  and  tries  to  establish  a  relationship  which  does  not 
really  exist.  In  dominant  ideas  the  imperious  character  of  the 
idea  overriding  all  other  processes  of  association  is  a  most 
marked  feature. 

The  examination  in  regard  to  the  occurrence  of  hallucina- 
tions or  illusions  is  frequently  beset  with  many  difficulties,  par- 
ticularly as  many  patients  are  extremely  sensitive  and  refuse  to 
admit  their  occurrence.  Not  uncommonly  the  examiner  by 
watching  the  actions  of  the  patient  may  be  led  to  infer  that 
definite  hallucinations  occur,  and  if  such  is  the  case,  it  is  im- 
portant to  determine  their  nature:  whether  they  are  primary 
or  secondary  in  character  and  whether  they  seem  to  bear  any 
relation  to  defects  in  the  sensory  apparatus;  whether  their 
subjectivity  is  marked  and  whether  they  are  stable  or  mobile, 
unilateral  or  bilateral.  For  the  points  to  be  noted  in  connection 
with  insane  ideas  and  the  other  phenomena  of  alienation  the 
reader  is  referred  to  Chapter  III. 

Examination  of  the  Cerebrospinal  Fluid. — A  complete  ex- 
amination of  the  cerebrospinal  fluid  includes  a  determination  of 
the  character  of  the  cellular  and  bacterial  elements  present  as 
well  as  of  the  physical  and  chemical  qualities.  Numerous 
methods  have  been  suggested  for  obtaining  specimens,  and 
inasmuch  as  so  many  varying  factors  must  be  taken  into  account 
in  the  examination  of  the  fluid,  it  is  essential  that  no  precau- 
tions should  be  omitted  to  prevent  the  occurrence  of  discrepan- 
cies in  the  results  of  the  observation.  Recently  Meyer  3  has 
redirected  attention  to  the  necessity  not  only  of  carrying  out 
the  procedure  with  the  strictest  aseptic  precautions,  but  also  of 
observing  certain  rules  in  the  examination  of  the  fluid  after  its 
withdrawal.  He  recommends  the  technique  employed  by 
Sicard.4  At  least  3  or  4  centimetres  of  the  spinal  fluid 
are  drawn  off  into  a  sterile  tube  and  at  once  centrifugalized. 

3  Meyer,    Ernst :     Ueber    Cytodiagnostik.    Untersuchung    des    Liquor 
Cerebrospinalis.     Berl.  klin.  Wchnschr.,  1904,  Feb.  1,  Nr.  5,  S.  105. 

Sicard  and  Monod :  Examen  histologique  du  liquide  cephalo- 
rachidien  dans  les  meningo-myelites.     Bull,  de  la  soc.  med.  des  Hop.,  1901. 


144  PSYCHIATRY 

The  French  writers  prefer  to  employ  a  centrifuge  capable  of 
making  3000  revolutions  and  the  process  is  completed  in  ten 
minutes,  but  when  the  rotation  is  slower  (2500  to  the  minute) 
at  least  half  an  hour  is  necessary.  The  technique  has  been 
described  in  detail  by  Nissl.5  After  centrifugation  is  com- 
pleted the  fluid  is  carefully  poured  off  into  a  reagent  glass.  A 
glass  pipette  is  then  introduced  into  the  tube  so  as  not  to  touch 
the  sides  and  the  substances  on  the  bottom  are  carefully  sucked 
up.  The  contents  of  the  pipette  are  then  blown  out  again  so 
that  a  better  mixture  of  all  the  elements  may  be  obtained.  The 
second  time  the  contents  of  the  pipette  are  carefully  blown  out 
on  to  three  glass  slides,  care  being  taken  that  the  drops  be 
equal  in  size.  The  slides  after  being  allowed  to  dry  in  the  air 
are  brought  for  half  an  hour  into  equal  parts  of  absolute  alcohol 
and  ether.  For  staining  Unna's  polychrome  methylene-blue 
solution  is  used,  a  few  drops  being  allowed  to  remain  on  the 
specimen  for  ten  minutes,  being  then  washed  off  with  distilled 
water;  the  slides  are  then  passed  through  alcohol  and  xylol, 
and  the  specimen  is  mounted  in  balsam  with  a  thin  cover-glass. 
Ravaut6  differentiates  between  a  decided  reaction  (grosse 
reaction)  when  from  20  to  150  cell  elements  are  found  in  the 
field  of  the  oil  immersion,  a  moderate  reaction  (reaction  moy- 
enne)  when  from  7  to  20,  a  suggestive  reaction  (reaction  dis- 
crete) when  from  4  to  6,  and  a  negative  reaction  (reaction 
nulle)  when  only  2  or  3  lymphocytes  occur  in  each  field.  Ac- 
cording to  Sicard,  with  a  Leitz  objective  No.  7,  giving  a  mag- 
nification of  from  300  to  400  times,  the  presence  of  3  or  4 
lymphocytes  in  the  field  may  be  regarded  as  normal.  In  some 
pathological  cases,  however,  a  great  increase  in  their  number 
is  observed.  In  many  instances  the  cells  having  a  pale-blue 
nucleus  somewhat  larger  than  that  of  the  lymphocyte,  with 
granular  masses  in  the  body  and  showing  a  tendency  to  stain  a 
reddish  tinge,  are  noted.     Morphologically  these  elements  re- 

6  Die  Bedeutung  der  Lumbalpunktion  fiir  die  Psychiatric  Centralbl. 
f.  Nervenheilk.  u.  Psych.,  April,  1904. 

*  Le  Liquide  cephalorachidien  des  syphilitiques  en  periode  secondaire. 
Annales  de  Dermatologie  et  de  Syphiligraphie,  4  serie,  tome  iv,  p.  537. 


EXAMINATION    OF    PATIENTS  145 

semble  mast-cells,  and  Meyer  is  inclined  to  regard  them  as 
small  mononuclear  leucocytes.  A  lymphocytosis  of  varying 
degrees  has  been  noted  in  dementia  paralytica,  tabes,  tuber- 
culous meningitis,  chronic  alcoholism,  and  in  all  diseases  in 
which  there  is  an  involvement  of  the  meninges.  In  some  of 
Nissl's  cases  polynuclear  leucocytes  were  seen,  but  their  signif- 
icance is  not  clear.  It  is  important  to  note  that  the  cellular  ele- 
ments in  the  spinal  fluid  vary  considerably,  and  that  at  the  first 
and  second  puncture  it  may  be  impossible  to  demonstrate  the 
presence  of  lymphocytes,  whereas  on  a  third  occasion  a  num- 
ber of  cells  may  be  found.  The  procedure  is  indicated  in  all 
doubtful  cases,  especially  when  it  is  necessary  to  differ- 
entiate between  functional  and  organic  disorders,  although  the 
exact  significance  of  the  findings  cannot  as  yet  be  clearly  de- 
fined. 

For  the  estimation  of  the  pressure  of  the  spinal  fluid  many 
methods  of  procedure  have  been  employed,  but  the  results 
so  far  obtained  do  not  permit  of  the  formation  of  a  definite 
opinion.  Considerable  differences  have  been  frequently  noted 
depending  upon  whether  the  patient  occupies  the  recumbent 
or  the  sitting  posture.  At  present  very  little  is  known  regard- 
ing the  secretion  or  circulation  of  the  spinal  fluid.  As  regards 
the  importance  of  the  results  to  be  obtained  from  chemical 
analyses  opinions  vary  widely.  Thus  Schaeffer  holds  that  the 
increase  of  albuminous  constituents,  so  frequently  noted,  is 
directly  due  to  inflammatory  changes  in  the  meninges  and  not, 
as  others  believe,  the  result  of  similar  changes  in  the  nervous 
system  in  other  parts  of  the  body.  For  a  detailed  account  of 
the  results  of  the  chemical  analyses  the  reader  is  referred  to  the 
work  of  Guillain  and  Parant 7  as  well  as  that  of  Coriat.8 


7  Sur  la  presence  d'albumines  coagulables  par  la  chaleur  dans  de  liquide 
cephalorachidien  des  paralytiques  generaux.  Revue  Neurologique,  No.  5, 
30  Avril,  1903. 

8  The  Chemical  Findings  in  the  Cerebrospinal  Fluid  and  Central  Ner- 
vous System  in  Various  Mental  Diseases.  The  American  Journ.  of  In- 
sanity, 1904,  vol.  lx,  No.  4. 


CHAPTER   V 

THE  TREATMENT  OF  CASES  OF  ALIENATION  1 

During  the  nineteenth  century  marvellous  changes  took 
place  in  the  methods  of  caring  for  and  treating  cases  of 
alienation.  The  removal  of  the  insane  from  dungeons,  through 
the  exertions  of  Pinel,  marked  the  beginning  of  a  new  epoch 
in  psychiatry;  but  no  less  important  was  the  second  era,  her- 
alded by  the  introduction  into  psychiatry  of  modern  clinical 
methods  and  the  establishment  on  the  Continent  of  Europe,  par- 
ticularly in  Germany,  of  fully  equipped  hospitals  for  the  insane 
closely  affiliated  with  the  universities.  In  the  older  institutions 
the  dominant  idea  in  the  plan  of  organization  had  regard  merely 
to  the  detention  of  the  patients,  and  it  is  in  this  respect  that  the 
modern  hospital  for  the  insane  shows  a  radical  divergence. 
Within  the  last  thirty  years  as  remarkable  a  change  has  taken 
place  in  the  treatment  of  the  insane  as  in  the  improvement  of 
surgical  methods.  Unfortunately,  in  institutions  in  the  United 
States,  with  few  exceptions,  the  detention  character  is  still 
primary,  and  opportunities  for  successfully  treating  patients  are 
still  few  and  incomplete,  inasmuch  as  the  existing  organization 
and  imperfect  equipment  do  not  make  it  possible  to  give  them 
the  benefit  of  the  best  medical  skill.  Nor  will  this  defect  be 
remedied  until  we  in  this  country  have  learned  to  appreciate  that 
proficiency  in  psychiatry  can  be  obtained  only  in  institutions  in 
which  the  interest  of  the  alienist  in  his  profession  is  kept  alive 
by  abundant  facilities  for  study  and  his  energy  is  stimulated  by 
the  presence  of  students  for  whose  training  he  is  responsible. 
The  establishment  of  psychiatrical  hospitals  in  close  proximity 
to  other  university  clinics  affords  the  only  possible  solution  of 
the  fundamental  problems  with  which  we  are  now  confronted. 

1 A  System  of  Physiologic  Therapeutics,  vol.  viii — Rest ;  Mental 
Therapeutics — Suggestion,  by  Francis  X.  Dercum.  Phila.,  1903.  Gastpar, 
A. :   Die  Behandlung  Geisteskranker.    Stuttgart,  1903. 

146 


GENERAL   TREATMENT  I47 

Among  the  manifold  advantages  to  be  obtained  in  this  way 
two  are  deserving  of  special  mention  here:  (i)  only  in  this 
way  can  we  command  a  supply  of  alienists  thoroughly  com- 
petent to  practise  and  teach  their  specialty;  (2)  only  when 
every  medical  student  is  given  the  opportunity  under  competent 
supervision  to  observe  and  become  acquainted  with  the  various 
clinical  phases  of  insanity  can  we  hope  that  the  general  prac- 
titioner will  finally  become  sufficiently  educated  along  these 
lines  to  recognize  the  development  of  alienation  in  its  earliest 
stages,— the  period  when  the  best  results  may  be  hoped  for  in 
combating  the  ravages  of  this  scourge.  There  is  no  branch  of 
medicine  in  which  the  ounce  of  prevention  is  of  greater  value. 
Many  cases  which  now  become  hopelessly  chronic,  if  the  diag- 
nosis were  made  earlier  in  the  disease  and  the  proper  condi- 
tions for  treating  the  patient  were  provided,  might  readily  be 
cured. 

Prophylactic  Measures.— In  the  section  devoted  to  the 
discussion  of  the  etiology  of  insanity  sufficient  has  been  said  to 
indicate  what  measures  may  be  instituted  to  prevent  the  spread 
of  alienation.    Although  various  factors  concerned  in  the  trans- 
mission of  normal  or  abnormal  mental  qualities  are  still  very 
imperfectly  understood,  common-sense  and  experience  justify 
us  in  maintaining  that  in  the  vast  majority  of  cases  it  is  better 
that  individuals  who  have  shown  signs  of  mental  aberration 
should  not  marry.     Hence  it  follows  that  one  of  the  most  im- 
portant reasons   for  making  ample  provision  in  every  com- 
munity for  the  care  of  the  insane  is  to  deprive  individuals  who 
are  bereft  of  reason  of  the  opportunity  to  propagate  their  kind. 
The  actual  encouragement  sometimes  given  by  physicians  to 
those  who  are  physically  and  mentally  unfit  to  marry  and  the 
public  indifference  to  the  necessity  of  restraining  epileptics  and 
those  who  are  mentally  defective  from  having  children  are  a 
serious  menace  to  society.     Only  those  who  are  familiar  with 
the  conditions  that  prevail  in  the  higher  as  well  as  in  the  lower 
classes  fully  realize  the  important  sociologic  bearing  of  this 
problem.    As  has  been  pointed  out,  many  of  the  vagabonds  and 
tramps  who  are  prone  to  indulge  their  sexual  impulses  pro- 


148  PSYCHIATRY 

miscuously  are  subject  to  various  forms  of  alienation,  it  having 
been  estimated  that  in  Germany  at  least  15  per  cent,  of  this 
class  were  insane.2  But  although  it  is  desirable  for  the  good  of 
the  community  that  only  individuals  who  are  mentally  sound 
should  propagate  their  kind,  it  is  scarcely  to  be  expected  that 
the  passage  of  laws  similar  to  the  one  enacted  in  Minnesota  will 
to  any  degree  regulate  or  do  away  with  the  possibility  of  mar- 
riages among  those  who  are  mentally  defective.  Hence  we  are 
left  with  only  two  methods  by  which  these  dangers  can  be  met, 
— namely,  ample  provision  for  these  poor  unfortunates  in  in- 
stitutions or,  if  they  be  left  at  large,  castration. 

Whenever  an  individual  presents  symptoms  that  in  any 
way  suggest  the  possible  outbreak  of  an  attack  of  alienation 
which  might  be  fraught  with  danger  to  himself  or  the  com- 
munity, he  should  immediately  be  kept  under  constant  observa- 
tion until  the  physician  has  been  able  to  establish  at  least  a  ten- 
tative diagnosis;  but  this  can  be  satisfactorily  and  quickly 
accomplished  only  in  cities  where  reception  hospitals  have  been 
established.  In  communities  where  such  institutions  do  not 
exist,  it  remains  for  us  to  do  the  next  best  thing,  and  at  once 
remove  him  to  an  asylum,  where  he  can  be  under  constant 
observation  until  further  developments  occur.  Not  only  is  this 
step  necessary  to  prevent  any  disastrous  results  to  others,  but 
it  is  the  one  which  will  best  serve  the  interests  of  the  patient. 
In  properly  constructed  and  fully  equipped  hospitals  for  the 
insane  even  the  milder  cases  of  alienation  have  a  far  better 
chance  for  a  rapid  recovery,  and  experience  has  shown  that 
mental  depression  always  tends  to  deepen  and  excitement  to  be 
exaggerated  when  the  patient  is  surrounded  by  individuals  or 
by  objects  with  which  he  has  been  familiar.  Unfortunately,  a 
misguided  sense  of  kindness  and  the  fear  of  damaging  the 
reputation  of  a  respectable  family  often  lead  to  a  temporizing 
policy,  and  the  patient  is  kept  at  home  until  all  hope  of  recovery 
has  vanished,  while  in  the  end  the  family  in  no  wise  escapes  the 


2  Wilmanns,   Karl :    Die   Psychosen  der  Landstreicher.     Centralbl.   f. 
Nervenheilk.  u.   Psych.,   1902,  Bd.  xii,  xxv.  Jahrgang. 


GENERAL   TREATMENT 


149 


terrible  slur.  Against  such  sentimentality  the  physician  who 
understands  anything  about  insanity  and  who  has  the  real  in- 
terest of  his  client  at  heart  will  sternly  set  his  face.  Not  but 
what  we  must  confess  that  the  prejudices  which  we  have  to 
overcome  are  not  wholly  unjustifiable,  inasmuch  as  the  majority 
of  institutions  in  the  United  States  are  poorly  adapted  to  care 
for  the  incipient  and  curable  types  of  alienation.  And  although 
we  may  be  convinced  that  even  an  imperfect  institution  can 
offer  better  results  than  the  home  in  the  majority  of  these  cases, 
we  should  never  rest  until  the  public  has  been  convinced  that 
the  best  will  in  the  end  prove  not  only  to  be  the  most  humane, 
but  also  the  most  economical. 

As  soon  as  the  patient  is  within  the  hospital,  if  the  symp- 
toms are  acute  or  subacute  in  character,  the  bed  treatment 
should  at  once  be  instituted.  This  rule  applies  also  to  the 
acute  exacerbations  occurring  during  the  course  of  a  chronic 
psychosis.  This  method  of  treatment,  to  be  successful,  necessi- 
tates all  the  adjuncts  of  the  modern  hospital, — trained  nurses,, 
facilities  for  bathing  and  other  hydrotherapeutic  measures,, 
massage,  electricity,  diet,  etc., — and  the  apparent  lack  of  success 
derived  from  it  must  often  be  attributed  to  the  fact  that  it  is 
attempted  in  institutions  that  are  in  the  transition  period  be- 
tween the  asylum  and  the  hospital  and  therefore  are  ill  adapted 
to  carry  out  all  the  various  procedures  necessary.  The  means 
used  to  quiet  excited  patients  next  demand  consideration. 
In  the  modern  hospital  for  the  insane  the  strait- jacket  and 
camisole,  except  in  very  rare  cases,  "  belong  in  the  garret," 
and  the  frequent  resort  to  these  mechanical  forms  of  restraint 
is  an  indication  of  the  existence  of  two  pernicious  conditions : 
(1)  a  lack  of  proper  bathing  facilities;  (2)  an  insufficient 
number  of  nurses.  In  institutions  which  are  not  properly 
equipped  for  the  carrying  out  of  hydrotherapy  mechanical 
restraint  often  becomes  a  necessity.  The  sheet  or  camisole  may 
then  be  employed  with  considerable  advantage  to  the  sufferer, 
as  nearly  every  insane  patient  soon  realizes  that  it  is  useless  to 
attempt  to  free  himself  and  get  out  of  bed.  On  the  other  hand, 
if  the  excited  patient  is  simply  allowed  to  go  on  struggling 


150 


PSYCHIATRY 


with  two  or  even  three  nurses,  violent  motor  restlessness  may 
be  kept  up  uninterruptedly  for  hours  until  both  patient  and 
nurses  are  utterly  exhausted. 

The  importance  of  the  continuous  rest  in  bed  for  patients 
suffering  from  acute  or  subacute  forms  of  alienation  can  hardly 
be  overestimated.  This  measure,  however,  cannot  be  success- 
fully carried  out  without  the  aid  of  physicians  and  nurses  who 
have  been  specially  trained  not  only  in  the  care  of  the  insane,  but 
also  in  the  wards  of  a  general  hospital,  and  have  a  thorough 
practical  knowledge  of  the  details  of  the  so-called  rest-cure. 
In  the  first  place,  unless  the  patient  is  carefully  tended  by  a 
skilful  nurse,  bed-sores  are  apt  to  develop.  This  complication 
can  be  obviated  by  bathing,  strict  attention  to  cleanliness,  the 
removal  of  all  possible  sources  of  pressure,  by  change  of  posi- 
tion, and  by  immediate  attention  to  small  excoriations  as  soon 
as  they  appear.  In  nearly  all  instances  the  monotony  may  be 
broken  by  the  institution  of  various  hydrotherapeutic  measures. 

No  definite  time  can  be  dogmatically  prescribed  during 
which  the  patient  should  be  kept  in  bed.  The  physician's  com- 
mon-sense and  experience  must  be  the  guide  in  all  such  matters. 
As  a  rule,  patients  who  have  lost  weight  and  are  anaemic  should 
be  kept  in  bed  until  they  have  shown  a  very  decided  improvement 
in  their  general  condition.  In  the  milder  cases  it  is  sufficient  to 
keep  the  patient  in  bed  for  a  week  or  ten  days ;  whereas  in  the 
severer  cases  two  or  three  months  are  necessary  in  order  to 
derive  the  most  satisfactory  results  from  the  treatment.  When 
the  proper  time  comes  the  bed  treatment  may  be  gradually 
broken  by  short  periods  during  which  the  patient  is  allowed  to 
sit  up.  Gradually  various  forms  of  exercise,  such  as  are  re- 
ferred to  later,  may  be  introduced.  For  a  more  detailed  descrip- 
tion of  the  rest-cure  the  reader  is  referred  to  the  publications  of 
Weir  Mitchell,  which  created  a  new  epoch  in  the  treatment  of 
nervous  and  mental  diseases,  as  well  as  to  Dercum's  excellent 
.  account  of  the  methods.3     Under  no  circumstances  should  the 


a  A  System  of   Physiologic  Therapeutics,  vol.   viii.     Edited  by   Solis 
Cohen.     Phila.,  1903. 


GENERAL   TREATMENT 


151 


patient  be  kept  continuously  in  bed  unless  he  can  be  under  the 
constant  supervision  of  a  well-trained  nurse.  The  monotony  of 
the  rest  in  bed  should  be  relieved  by  baths,  packs,  massage, 
passive  or  active  movements,  and  in  the  milder  cases  or  during 
the  periods  of  convalescence  by  the  nurse  reading  aloud  or 
occupying  the  patient's  attention  by  some  pleasant  and  not  too 
stimulating  form  of  mental  occupation. 

Hydrotherapy.4 — The  good  effects  to  be  derived  from 
appropriate  hydrotherapeutic  measures  in  the  treatment  of  cases 
of  alienation  are  becoming  more  and  more  appreciated  every 
day.  Among  the  more  important  of  these  procedures  is  the 
warm  bath.  The  water  should  be  at  a  temperature  of  from  340 
to  360  C.  The  tub  should  be  placed  in  a  room  in  the  isolating 
ward  especially  prepared  for  the  purpose,  or  a  portable  tub 
which  can  be  moved  about  from  one  room  to  another  may  be 
employed.  There  should  be  sufficient  water  in  it  to  afford  a 
considerable  degree  of  buoyancy,  so  that  there  is  little,  if  any, 
pressure  upon  the  various  parts  of  the  body  and  limbs.  If  nec- 
essary, one  or  more  rubber  air-cushions  may  be  introduced  to 
help  to  sustain  the  weight.  A  canvas  sheet  may  be  stretched 
over  the  tub,  great  care  being  taken  in  cases  of  excitement  or  of 
marked  mental  depression  that  the  patient  shall  have  no  chance 
of  strangling  himself  by  means  of  the  edge  of  the  sheet.  In- 
gress and  egress  of  the  water  supply  for  the  portable  tubs  may 
be  secured  by  means  of  a  long  hose  carried  to  the  nearest  bath- 
room. As  a  rule,  the  first  bath  should  last  from  fifteen  minutes 
to  one  hour.  In  many  cases  this  will  be  sufficient  to  lessen 
motor  restlessness  and  to  exert  a  beneficial  reflex  influence  upon 
the  states  of  anxiety,  but  the  submersion  may  be  prolonged  for 
several  hours  or  the  patient  kept  continuously  in  the  tub  for  one 
or  more  days.  Many  excited  patients  become  quickly  accus- 
tomed to  the  water  and  after  a  few  minutes  do  not  offer  any 
objection  to  the  continuance  of  the  bath.     In  each  case  it  is 


4  Ueber  die  Anwendung  der  physikalischen  Heilmethoden  bei  Nerven- 
krankh.  in  der  Praxis.  Hoffman,  1898.  Hydrotherapy.  A  System  of 
Physiologic  Therapeutics.     Phila.,  1903. 


152 


PSYCHIATRY 


better  that  a  physician  should  be  present  while  the  first  bath  is 
being  given  in  order  that  the  effects  upon  the  mental  and 
physical  state  of  the  patient  may  be  carefully  noted.  After  the 
patient  is  taken  from  the  tub  he  should  be  carefully  dried  and 
put  to  bed,  and  in  the  majority  of  acute  cases  kept  there  until  the 
next  bath  is  given.  When  for  various  reasons  it  is  impossible 
or  inadvisable  on  account  of  a  weak  heart,  cerebral  hemor- 
rhage, etc.,  to  give  a  tub-bath,  warm  packs  may  be  tried.  This 
procedure  is  carried  out  as  follows :  A  rubber  blanket  having 
been  placed  under  the  patient,  he  is  wrapped  in  a  warm  wet 
sheet  and  then  covered  over  with  a  woollen  blanket.  At 
intervals  the  blanket  is  removed  for  a  few  moments  and  the 
sheet  moistened  with  warm  water.  This  method  of  treatment 
will  often  be  found  to  be  very  beneficial  in  cases  of  acute 
alcoholic  delirium  as  well  as  the  mild  forms  of  insomnia  and 
hypomaniacal  states.  Sometimes  it  is  advisable  to  give  only 
one  tub-bath  in  the  twenty- four  hours  and  supplement  this  with 
warm  packs  every  four  or  six  hours.  Cold  baths  and  cold  packs, 
as  a  rule,  are  of  no  service  or  even  may  be  very  deleterious  in 
states  of  excitement,  but  later  may  be  used  with  considerable 
advantage  in  hypochondriasis  and  mild  states  of  depression. 
The  prolonged  warm  baths  are  particularly  useful  in  the  ex- 
cited stage  of  paresis  as  well  as  in  that  of  manic-depressive 
insanity,  collapse  delirium,  amentia,  and  Korsakow's  syndrome. 
Alter  has  given  an  interesting  account  of  the  beneficial  effects 
of  baths  in  the  treatment  of  protracted  cases  of  maniacal  excite- 
ment as  compared  with  those  obtained  from  the  use  of  drugs.5 
It  can  not  be  denied  that  any  properly  conducted  hydrothera- 
peutic  regime  makes  very  considerable  demands  upon  the  time 
and  energies  of  the  nurses  and  attendants,  but  so  far  as  its 
value  in  the  treatment  of  various  mental  conditions  is  concerned 
experience  has  shown  that  from  its  employment  many  patients 
will  derive  benefits  which  it  has  not  been  found  possible  to 
obtain  by  any  other  means  at  our  disposal. 

0  Alter,  W. :  Versuche  mit  zellenloser  Behandlung  und  hydrothera- 
peutischen  Massnahmen.  Centraibl.  f.  Nervenheilk.  u.  Psych.,  1902,. 
Marz,  N.  F.,  Bd.  xv,  xxv.  Jahrgang. 


GENERAL    TREATMENT 


153 


Massage  is  a  very  important  adjunct  in  the  treatment  of 
certain  forms  of  alienation,  such  as  psychasthenia,  neuras- 
thenia, hysteria,  the  milder  stages  of  manic-depressive  insanity, 
particularly  the  period  of  depression,  and  during  convalescence 
from  all  the  more  acute  psychoses.  Not  only  is  it  indicated 
during  periods  of  mental  depression,  but  it  often  proves  dis- 
tinctly beneficial  in  certain  of  the  very  mild  maniacal  states. 
Instead  of  forcing  patients  who  are  mentally  depressed  to 
exert  themselves  or  to  expend  any  little  energy  they  may  have 
accumulated  in  getting  out  of  bed  and  taking  walks,  it  is  far 
better  that  they  should  be  kept  flat  on  their  backs  and  exercise 
administered  to  them  in  the  form  of  massage  or  passive  move- 
ments. This  may  be  given  once  or  twice  a  day  according  to 
the  indications  in  the  particular  case.  The  reactions  of  patients 
vary  considerably,  and  sometimes  it  is  found  desirable  to  give 
the  massage  in  the  morning,  at  other  times  at  night,  while  many 
patients  can  take  it  twice  a  day,  morning  and  night,  with  bene- 
fit. In  any  case  the  degree  of  force  used  and  the  duration  of 
each  treatment  depend  very  largely  upon  the  condition  of  the 
patient. 

Various  gymnastic  exercises  in  the  form  of  the  so-called 
German  or  Swedish  movements  can  often  be  employed  with 
great  benefit.  The  former  are  generally  a  variety  of  simple 
active  movements  somewhat  similar  to  those  frequently  taught 
in  the  schools.  In  some  cases  the  patients  may  be  allowed  to 
hold  in  their  hands  sticks  or  light  dumb-bells  while  carrying  out 
the  exercises.  The  latter  are  a  variety  of  more  complicated 
movements,  a  description  of  which  will  be  found  in  special 
hand-books.  Many  of  these  forms  of  exercise  are  indicated 
when  the  patient  is  up  and  about  the  wards,  and  some  of  the 
milder  forms  may  be  tried  while  he  is  still  in  bed.  They  are 
particularly  valuable  when  the  individual  is  just  entering  upon 
the  stage  of  convalescence  and  when  it  is  desirable  that  only  a 
certain  amount  of  physical  exercise  should  be  taken  without 
materially  increasing  his  sense  of  effort.  Under  supervision 
the  patient  is  allowed  to  execute  a  number  of  movements,  such 
as  raising  and  elevating  the  arms  or  legs,  care  being  taken 


154 


PSYCHIATRY 


not  to  overtax  his  strength.  In  this  way  many  of  the  muscles 
are  brought  into  play  before  the  time  comes  at  which  walking 
should  be  attempted.  V.  Bechterew  6  for  several  years  has 
successfully  carried  out  this  practice  of  having  patients  who 
were  feeble  or  who  were  afflicted  with  various  forms  of 
paralyses  taught  to  execute  a  series  of  movements  while 
in  the  full-bath.  In  some  instances  where  the  active  move- 
ments can  not  be  successfully  carried  out,  the  nurse  or 
attendant  may  use  the  various  passive  movements.  Such 
practices  are  of  great  use  not  only  for  the  physical  effect  that 
they  have  upon  the  patient  in  stimulating  the  circulation,  but 
also  for  the  influence  exerted  upon  the  mental  condition,  since 
they  aid  in  distracting  the  patient's  attention  from  himself  and 
in  keeping  his  mind  more  or  less  occupied.  As  an  adjunct  to 
the  means  already  indicated  a  plentiful  supply  of  fresh  air  is  all- 
important.  Nothing  can  be  worse  for  patients  than  the  tem- 
perature of  the  wards  through  which  one  frequently  has  to  pass, 
particularly  in  the  institutions  where  steam  heat  is  employed. 
In  fact,  in  not  a  few  of  our  insane  asylums  not  only  the  patients 
themselves,  but  the  attendants  and  members  of  the  medical  staff, 
have  been  known  to  suffer  severely  from  the  close,  impure,  and 
overheated  atmosphere  in  which  they  have  to  spend  so  large 
a  portion  of  their  time.  For  a  certain  part  of  every  day,  par- 
ticularly when  the  sun  is  shining,  even  in  cold  weather,  bed 
patients  should  be  well  protected  with  a  sufficiency  of  coverings 
and  two  or  three  times  a  day  the  windows  in  the  ward  should 
be  opened  wide  for  several  minutes.  Patients  suffering  from 
mental  depression,  when  the  motor  restlessness  is  not  marked, — 
or,  in  fact,  in  a  variety  of  other  conditions  where  there  is  little 
or  no  excitement, — may  be  wheeled  out-of-doors  in  bed  and  left 
there  under  the  supervision  of  an  attendant  for  several  hours. 
It  is  much  to  be  regretted  that  whereas  the  facilities  for  such 
treatment  exists  in  some  of  our  general  medical  hospitals,  they 
are  for  the  most  part  lacking  in  the  institutions  to  which  acute 


6  Heilgymnastiche    Behandlung  im    Bade.      Centralbl.   f.   Nervenheilk. 
u.  Psych.,  Marz  15,  1904. 


GENERAL   TREATMENT 


155 


mental  cases  are  consigned.  Nothing  can  be  more  strongly 
condemned  than  the  practice  of  allowing  anaemic,  sallow-look- 
ing patients  to  remain  seated  in  their  rooms  or  in  the  corridors 
for  hours  at  a  time  without  a  breath  of  fresh  air,  whereas,  if 
proper  provision  were  made,  even  when  in  bed,  they  might  be 
kept  practically  out-of-doors,  and  when  able  could  be  kept  occu- 
pied by  massage,  gymnastics,  and  the  amusements  indicated  in 
each  individual  case.  In  every  institution  for  the  insane,  before 
it  becomes  worthy  to  be  called  a  hospital,  in  addition  to  a 
corps  of  thoroughly  trained  nurses  there  should  be  ample  fa- 
cilities for  carrying  out  the  rest-cure  and  hydrotherapy  in 
all  its  details.  Moreover,  certain  of  the  attendants  should  be 
skilled  in  giving  massage,  and  there  should  be  at  least  one 
capable  of  giving  instruction  to  the  patients,  under  the  direc- 
tion of  the  physician,  in  various  gymnastic  exercises.  The 
apparatus  employed  need  not  be  elaborate  and  the  exercises 
could  be  carried  out  in  some  airy,  cheerful  room  set  apart  for 
that  purpose,  where  a  few  patients  could  be  taken  at  one  time. 
As  has  been  said,  for  acute  conditions  a  complete  or  some  modi- 
fied form  of  the  rest-cure  is  generally  indicated,  but  not  a  few 
patients,  particularly  those  afflicted  with  dementia  prsecox,  seem 
to  be  greatly  benefited  by  more  or  less  severe  exercise  in  the 
open  air. 

Mental  Treatment. — Not  so  very  long  ago  many 
articles  were  published  dealing  with  what  was  termed  the  "  men- 
tal treatment"  of  different  forms  of  alienation.  Undoubtedly 
many  insane  patients  are  particularly  susceptible  to  suggestion, 
and  we  have  already  pointed  out  that  much  of  the  benefit  to  be 
derived  from  massage,  hydrotherapy,  and  gymnastics  is  largely 
due  to  the  fact  that  the  patient's  attention  is  diverted  by  what 
is  being  done  for  him,  and  in  this  way  his  mind  is  stimulated 
gradually  to  more  normal  action.  Undoubtedly  a  few  cases  of 
alienation,  particularly  certain  hysterical  states,  are  temporarily 
improved  by  an  artificially  obtained  hypnotism,  but  that  per- 
manent beneficial  results  are  ever  brought  about  by  this  form  of 
treatment  is  highly  improbable,  and  the  general  consensus  of 
opinion  is  against  its  employment  in  institutions. 


156  PSYCHIATRY 

The  attitude  of  the  alienist  towards  his  patients  is  very- 
important.  He  should  always  tell  them  the  truth  and  should 
convince  them  that  his  conduct  towards  them  is  always  straight- 
forward. If  the  physician  is  once  found  to  have  practised  any 
form  of  deception,  no  matter  how  excellent  the  motive,  the 
patient  will  never  regain  the  confidence  in  him  which  is  abso- 
lutely necessary  for  the  accomplishment  of  any  good  results. 
The  higher  the  intellectual  state  of  the  patient  previous  to  the 
attack  of  alienation,  the  more  necessary  does  it  become  that  the 
medical  attendant  should  be  interested  even  to  the  point  of 
enthusiasm  in  all  that  pertains  to  his  profession.  Practical  ex- 
perience has  shown  that  many  of  the  more  intelligent  patients 
are  quick  to  note  the  mental  inertia  and  lack  of  scientific  interest 
on  the  part  of  medical  officers  of  hospitals  for  the  insane.  Dur- 
ing convalescence  the  patient  should  be  very  carefully  watched 
by  the  nurses  and  physicians  in  order  that  the  first  signs  of  a 
relapse  may  be  detected  and  met  by  proper  treatment.  Only 
exceptionally  should  he  be  permitted  to  see  members  of  his  own 
family  or  friends,  as  such  interviews  are  frequently  followed  by 
a  renewal  of  the  symptoms.  The  physical  condition  should  be 
carefully  noted,  and  in  all  hospitals  regular  charts  of  the  bodily 
weight  should  be  kept  in  such  a  manner  that  they  may  be  readily 
consulted  by  the  physician  on  his  daily  rounds.  In  manic- 
depressive  insanity,  or  the  acute  psychoses  more  particularly, 
the  rise  or  fall  in  bodily  weight  is  of  very  great  significance  in 
the  prognosis. 

A  few  more  specific  suggestions  regarding  the  treatment 
of  cases  of  acute  or  subacute  excitement  as  well  as  of  depression 
may  not  be  out  of  place  here.  When  individuals  are  maniacal 
it  is  nothing  less  than  inhuman  to  merely  confine  them  in  a 
single  room  about  which  they  are  allowed  to  roam  like  wild 
animals.  They  should  be  kept  either  in  bed  or  in  the  prolonged 
bath.  The  latter  may  be  given  immediately  upon  admission, 
if  the  patient  is  not  too  excited  or  in  too  exhausted  a  condition. 
In  all  forms  of  excitement  the  patients  are  frequently  consti- 
pated— a  condition  that  may  be  relieved  by  the  administration 
of  various  remedies,  preferably  calomel,  castor  oil,  or  croton  oil 


GENERAL   TREATMENT  1 57 

given  by  the  mouth.  Unless  some  contraindication  exists, 
the  bowels  should  be  moved  as  soon  as  the  patient  comes  to  the 
hospital.  Steps  should  also  be  taken  against  too  long  a  reten- 
tion of  the  urine.  When  the  water  is  not  passed  at  the  proper 
intervals,  warm  wet  cloths  should  be  applied  over  the  region  of 
the  bladder,  or  warm  sitz-baths  should  be  tried.  Sometimes 
the  urine  may  be  gently  expressed  from  the  bladder  by  means 
of  an  abdominal  manipulation  similar  to  that  employed  in  the 
removal  of  the  placenta.  On  account  of  the  danger  of  septic 
infection  catheterization  should  be  employed  only  as  a  last 
resort.  If  instrumental  relief  becomes  necessary,  the  strictest 
aseptic  precautions  should  always  be  taken,  and  if  it  becomes 
necessary  to  frequently  repeat  the  operation,  urotropin,  0.5 
gramme  two  or  three  times  a  day,  or  from  three  to  ten  drops 
of  turpentine  may  be  given.7 

Isolation  is  indicated  not  only  in  cases  of  acute  excitement, 
but  also  in  profound  mental  depression.  Nothing  is  more  un- 
fortunate than  the  method  of  treatment  of  mental  depression 
so  often  adopted  in  our  institutions,  which  allows  the  patients 
during  the  periods  of  deepest  depression  to  associate  with  other 
insane  individuals,  and. instead  of  keeping  them  in  bed  often 
compels  them  to  get  up  and  walk  about  the  wards.  This  is 
quite  analogous  to  the  treatment  of  such  cases  so  often  pre- 
scribed through  ignorance  by  the  general  practitioner,  who 
advises  patients  afflicted  with  mental  depression  to  travel.  On 
the  contrary,  all  such  patients  should  be  isolated  and  kept  in  bed, 
and  they  should  be  seen  only  by  the  physician  and  nurses  and 
not  allowed  to  interview  members  of  their  family.  In  many 
of  the  French  hospitals  hysterical  and  other  excited  patients 
frequently  have  their  beds  completely  surrounded  by  a  canopy 
or  tent  formed  of  sheets  supported  by  an  iron  framework.  The 
patient  is  permitted  to  raise  the  sheet  only  upon  the  approach 
of  the  physician  or  nurse,  and  in  this  way  can  be  kept  com- 
pletely isolated  for  days  at  a  time.     Intelligent  patients  who 


T  Pfister,  H. :    Die  Anwendung  von   Beruhigungsmitteln  bei   Geistes- 
kranken.    Halle  a/S.,  1903. 


158  PSYCHIATRY 

have  passed  through  periods  of  severe  mental  depression  dur- 
ing convalescence  frequently  complain  that  nothing  intensified 
their  suffering  so  much  as  to  be  urged  to  occupy  themselves 
or  to  be  driven  to  try  and  divert  their  attention  from  their 
own  troubles,  or  in  any  way  to  contrast  their  condition  with 
that  of  people  about  them.  In  fact,  they  feel  that  to  expend 
what  little  energy  they  may  have  possessed  in  trying  to  re- 
spond to  external  stimuli  could  only  result  in  harm.  Thus, 
for  example,  one  of  our  patients  declared  that  whereas  the 
most  detailed  and  elaborate  observation  of  the  physician  in 
no  way  fatigued  or  annoyed  him,  inasmuch  as  it  made  him  feel 
more  certain  that  every  effort  was  being  made  to  restore  him 
to  health,  at  the  same  time  his  feelings  of  depression  were 
rendered  much  worse  by  any  attempt  to  force  him  to  exert  him- 
self. The  more  acute  the  mental  depression  the  more  impera- 
tive the  indication  for  perfect  rest  in  bed. 

In  all  forms  of  acute  alienation  the  diet  is  of  great  im- 
portance, and  in  every  hospital  there  must  be  a  diet  kitchen  and 
an  instructor  thoroughly  trained  in  the  preparation  of  food. 
Until  the  physician  becomes  acquainted  with  a  case  and  sees 
how  the  patient  will  respond  to  treatment  a  fluid  diet  is  indi- 
cated. As  a  rule,  about  six  ounces  of  milk  every  two  or  three 
hours  will  be  sufficient;  but  in  some  rare  instances  where  the 
digestive  disturbances  are  marked  very  small  quantities  should 
be  given  every  hour  for  a  short  time.  If  the  milk  is  not  well 
tolerated,  eggs,  bouillon,  broths,  gruels,  the  various  wheat 
preparations,  or  rice  may  be  tried.  It  is  of  great  importance  that 
patients  should  drink  plenty  of  water,  either  plain  or  aerated. 
Even  when  only  fluid  substances  are  being  administered  it  is 
important  that  several  glasses  of  water  be  taken  every  day.  In 
many  instances  the  patient,  particularly  the  sufferer  from  hallu- 
cinations or  illusions,  will  refuse  nourishment  in  all  forms,  but 
by  dint  of  tact  and  kindness  the  nurse  or  attendant  will  often 
be  able  to  overcome  his  objections.  Whenever  it  can  possibly 
be  avoided,  it  is  undesirable  to  arouse  the  antagonism  of  the 
patient  by  peremptory  commands.  In  some  instances  where 
nourishment  is  not  immediately  indicated  the  patient  may  be 


GENERAL   TREATMENT  1 59 

allowed  to  go  for  several  hours,  after  which  it  will  often  be 
found  that  his  objections  have  disappeared  and  some  form  of 
food  is  taken  gladly.  In  some  cases  when  the  patient  can  be 
trusted,  if  the  food  is  put  within  his  reach  and  the  nurse  leaves 
the  room,  he  will  take  it  when  he  finds  himself  unobserved. 
Great  caution,  however,  should  be  exercised  in  leaving  patients 
alone.  Either  the  motor  restlessness  or  psychomotor  retarda- 
tion may  be  great  enough  to  interfere  with  the  taking  of  food. 
In  these  cases,  as  well  as  in  those  in  which  the  refusal  to  take 
food  is  the  result  of  some  delusion,  forced  feeding  must  be 
resorted  to.  When  this  procedure  is  necessary  the  patient  is 
made  to  sit  up  in  bed  in  order  to  avoid  regurgitation  or  vomit- 
ing. The  instruments  necessary  are  a  soft  rubber  sound  of 
about  70  centimetres  in  length  and  from  .8  to  1.5  centimetres 
thick,  similar  to  a  Nelaton's  catheter.  For  various  reasons  it  is 
preferable  that  the  outlet  of  the  sound  should  be  in  the  end  and 
not  in  the  sides,  but  if  one  with  lateral  openings  is  used  care 
should  be  taken  that  their  edges  are  smooth  In  the  majority  of 
the  excited  states  as  well  as  in  the  stuporous  cases  it  is  impossi- 
ble to  introduce  the  sound  through  the  mouth  without  the  use  of 
considerable  force,  which  is  always  undesirable.  In  these  cases 
the  passage  through  one  or  other  of  the  nostrils  can  be  utilized. 
Only  mild  pressure  should  be  used  and  the  sound  should  never 
be  rotated,  as  the  nasal  mucous  membrane  is  delicate  and  can 
very  readily  be  injured.  As  the  sound  passes  the  pharynx  reflex 
gagging,  coughing,  or  an  excessive  flow  of  saliva  and  disturb- 
ances in  respiration  often  result.  Intense  reflex  coughing,  cya- 
nosis, and  difficult  breathing  usually  indicate  that  the  instrument 
has  been  passed  into  the  trachea,  and  in  such  cases  it  should  be 
at  once  withdrawn.  If  the  patient  be  made  to  bend  his  head 
slightly  forward,  not  only  the  flow  of  saliva  from  the  mouth,  but 
also  the  opening  of  the  pharyngeal  passage  will  be  facilitated. 
If  too  great  haste  is  not  used,  the  reflexes  become  less  active  and 
permit  of  the  further  advancement  of  the  sound.  Very  ob- 
streporous  patients  are  sometimes  able  to  temporarily  prevent 
the  sound  from  passing  the  pharynx,  in  which  case  the  instru- 
ment is  withdrawn  and  then  carefully  reintroduced.     When 


160  PSYCHIATRY 

the  sound  finally  reaches  the  stomach  the  outer  end  is  attached 
to  a  glass  tube,  which  is  in  turn  connected  with  the  rubber 
inflator  (Politzer  bag)  or  Davidson's  syringe.  The  glass  tube 
and  syringe  should  be  filled  with  the  fluid  nourishment,  so  that 
as  little  air  as  possible  may  be  injected  into  the  stomach  when 
the  bulb  is  squeezed.  As  soon  as  the  food  has  been  introduced 
into  the  stomach  the  sound  and  glass  tube  are  disconnected,  and 
the  former  is  withdrawn  slowly  until  the  end  is  through  the 
pharynx,  when  it  may  be  more  quickly  removed  from  the  nose. 
In  unconscious  patients,  if  regurgitation  of  the  fluid  threatens, 
the  tube  should  at  once  be  withdrawn.  When  there  is  much 
tendency  to  vomiting  after  forced  feeding,  subcutaneous  in- 
jections of  morphin  or  the  admixture  of  a  small  amount  of 
opium  with  the  fluid  introduced  through  the  catheter  gives 
satisfactory  results.  Various  forms  of  fluid  nourishment  may 
be  administered  in  this  way,  and  experience  has  shown  that 
patients  may  be  kept  alive  in  this  manner  for  considerable 
periods  of  time.  Some  such  formula  as  the  following:  Milk, 
750  cubic  centimetres ;  eggs,  3 ;  sugar,  1 50  grammes,  may  be 
given  two  or  three  times  a  day.  In  some  instances  small  quan- 
tities of  lemon- juice  or  the  drugs  indicated  for  the  particular 
case  may  be  mixed  with  the  fluid.  In  cases  of  haemophilia, 
haemoptysis,  weak  heart,  or  where  vomiting  might  prove  to  be  a 
source  of  danger  in  itself,  this  form  of  feeding  is  contra- 
indicated.  Nutritive  enemata  either  alone  or  as  an  adjunct  to 
other  forms  of  feeding  are  at  times  of  great  service.  These  are 
best  preceded  by  a  rectal  injection  of  lukewarm  water  to  which, 
when  necessary,  glycerin  or  olive  oil  has  been  added.  After 
the  lower  bowel  is  thoroughly  cleansed  an  opium  suppository 
may  be  introduced,  and  in  fifteen  minutes  or  half  an  hour  later 
the  nutritive  enema. 

Electrotherapy. — In  the  treatment  of  mental  cases 
electricity  is  not  of  very  great  value.  In  the  milder  forms  of 
depression,  neurasthenia,  or  hypochondriasis,  the  Holz  machine 
may  be  used  with  some  benefit.  Occasionally  where  the  patient 
is  open  to  suggestion  temporary  beneficial  effects  follow  the  use 
of  the  faradic  current.     The  local  paralyses  that  are  relieved 


GENERAL   TREATMENT  161 

by  the  use  of  galvanism  are  of  neurological  rather  than  psy- 
chiatrical interest. 

Medicinal  Therapy. — With  the  exception  of  mercury  and 
the  iodides  for  the  amelioration  of  some  of  the  milder  mental 
disturbances  dependent  upon  syphilis,  or  of  quinine  in  cutting 
short  the  acute  delirium  associated  with  malaria,  and  the  thy- 
roid extract  in  myxcedema  and  cretinism,  we  possess  no  specific 
drugs  for  the  treatment  of  alienation. 

Opium  may  be  administered  in  various  forms  to  quiet  ex- 
cited patients  or  lessen  pain.  As  a  rule,  it  is  best  to  begin  with 
small  doses,  given  three  or  four  times  a  day  and  gradually  in- 
creased if  necessary.  Many  of  the  mild  forms  of  excitement  or 
anxiety  quickly  respond  to  this  form  of  treatment. 

Comparatively  large  doses  of  opium  have  been  recom- 
mended by  Flechsig  in  the  treatment  of  mental  depression.  In 
the  more  chronic  cases,  however,  great  caution  is  necessary  in 
order  to  guard  against  ill  effects  from  the  drug  upon  the  gastro- 
intestinal tract.  Morphin  in  the  form  of  Magendie's  solu- 
tion in  doses  of  5  to  10  drops  may  be  substituted  for  opium, 
especially  when  subcutaneous  injections  are  employed.  Great 
care  must  be  taken  that  during  the  stage  of  convalescence  the 
patient  does  not  become  an  habitue  of  the  drug. 

Hyoscin  is  serviceable  in  various  forms  of  acute  excite- 
ment, although  many  authors  object  to  its  use  when  the  mania- 
cal symptoms  are  very  marked.  Where  it  is  necessary  to  quiet 
the  patient  quickly,  so  that  the  transportation  to  the  hospital 
may  be  effected  at  once  and  with  as  little  disturbance  as  possible, 
this  drug  is  very  useful.  Hyoscin  may  be  given  in  combination 
with  morphin. 

Scopolamin  (hydrobromate)  may  be  administered  by  the 
mouth  in  doses  of  from  one-two-hundredth  to  one-one-hun- 
dredth of  a  grain  (.0003  to  .0006  gramme),  or  hypodermically 
in  doses  of  one-four-hundredth  to  one-two-hundredth  of  a 
grain  (.00015  to  .0003  gramme).  In  acute  stormy  deliriums 
this  drug,  if  given  with  great  care,  is  particularly  useful  in 
quieting  the  patients.  Many  authors  have  reported  instances 
of  delirium  following  the  use  of  hyoscin  and  scopolamin,  but 


1 62  PSYCHIATRY 

such  results  have  not  been  observed  at  the  Sheppard  and  Enoch 
Pratt  Hospital.8  As  a  rule,  after  an  interval  of  half  an  hour 
following  the  administration  of  scopolamin  the  patient  falls 
into  a  quiet  sleep,  which  is  occasionally  preceded  by  a  dryness 
in  the  throat,  an  increased  sense  of  fatigue,  and  more  rarely  by 
slight  disturbances  in  coordination  of  movement.  If  the  first 
dose  is  not  successful,  another  may  be  administered  after  one"  or 
two  hours,  but  a  third  dose  is  not,  as  a  rule,  either  indicated  or 
necessary.  This  drug  has  been  very  successfully  used  in  all 
forms  of  acute  excitement,  particularly  the  excited  periods 
belonging  to  manic-depressive  insanity,  paresis,  epilepsy,  acute 
delirium  due  to  alcohol  or  other  causes,  and  catatonia.  Some- 
times the  combination  of  scopolamin  with  morphin  seems  to 
exert  a  beneficial  effect.  The  drug  is  contraindicated  in  the 
presence  of  any  marked  cardiac  complication,  feeble  pulse,  or 
very  advanced  arteriosclerotic  conditions.  No  cumulative 
effects  have  been  noticed.  Various  other  hypnotics  are  often 
useful;  amylene  hydrate  in  doses  of  from  i  to  3  cubic  centi- 
metres (15  to  45  minims),  sulfonal  1  to  2  grammes  (15  to  30 
grains),  trional  1  to  2  grammes  (15  to  30  grains). 

Just  recently  veronal  has  attracted  considerable  attention. 
A  single  dose  of  0.5  to  1.0,  or  exceptionally  1.5  to  2  grammes, 
may  be  given  in  hot  water,  tea,  or  coffee.  It  is  said  to 
act  within  from  thirty  minutes  to  one  hour.  No  bad  after- 
effects have  been  noted  except  in  seven  cases  reported  by 
Fischer,9  in  which  there  was  an  unpleasant  feeling  in  the  head, 
somnolence,  and  in  one  case  nausea  and  vomiting.  Abraham,10 
who  tried  the  drug  extensively  in  the  excited  periods  of  de- 
mentia paralytica,  was  not  favorably  impressed  with  the  results 


8  Bumke :  Skopolaminum  hydrobromicum.  Monatsschr.  f.  Psych,  u. 
Neurol.,  xiii,  1  u.  2.  Van  Vleuten,  C.  F. :  Ein  Delirium  in  Anschluss 
an  Hyoscinmissbrauch.  Centralbl.  f.  Nervenheilk  u.  Psych.,  1904,  Nr. 
168,  Jahrg.  xxvii,  S.  19. 

8  Ueber  die  Wirkung  des  Veronal.  Therapeut.  Monatsheft,  1903, 
Jahrg.  xvii,  August  3.  393. 

10  Ueber  Versuche  mit  Veronal  bei  Erregungszustanden  der  Paralytiker 
Centralbl.  f.  Nervenheilk.  u.  Psych.,  Marz  15,  1904. 


GENERAL   TREATMENT  163 

obtained.  Its  use  has  been  highly  recommended  by  many  com- 
petent observers  in  the  treatment  of  simple  insomnia. 

Paraldehyde,  in  spite  of  its  nauseous  taste,  is  extensively 
used.  It  seems  to  have  no  unpleasant  after-effects  and  has  been 
strongly  recommended  in  all  forms  of  alcoholism  and  in  various 
types  of  mania.  It  is  supposed  to  be  of  special  value  in  the 
senile  and  arterio-sclerotic  forms  of  alienation.  Cumulative 
action  and  idiosyncrasies  for  the  drug  have  not  been  noted  even 
when  its  use  has  been  continued  for  a  long  time.  The  dose 
is  from  15  to  60  minims  ( 1  to  4  cubic  centimetres)  largely 
diluted  with  syrup  and  flavored  with  tincture  of  orange  peel 
or  some  aromatic.  Cases  of  the  paraldehyde  habit  are  not 
uncommon. 

The  bromides  are  still  considered  of  great  value.  They 
are  particularly  useful  in  cases  of  excitement  with  sexual  mani- 
festations as  well  as  in  the  forms  associated  with  epilepsy. 
They  are  sometimes  very  efficient  in  cases  of  insomnia  due  to 
the  milder  forms  of  maniacal  excitement.  The  potassium  and 
sodium  salts  as  well  as  bromipin  are  most  commonly  employed. 
Their  continuous  use,  however,  in  large  doses,  is  apt  to  set  up 
gastro-intestinal  disturbances  and  occasionally  severe  toxic 
symptoms,  and  patients  who  have  been  taking  them  for  a  long 
time  often  show  considerable  disturbances  in  associative 
memory,  acne,  loss  of  appetite,  and  foul  breath.  Individual 
idiosyncrasies  are  not  uncommon. 

Within  the  past  decade  chloral  hydrate,  in  doses  from  5 
to  20  grains  (.3  to  1.3  grammes),  has  been  less  frequently 
employed  on  account  of  various  toxic  symptoms,  such  as  slow- 
ing of  the  heart's  action,  irregular  pulse,  and  various  dis- 
turbances of  the  gastro-intestinal  tract,  which  sometimes  follow 
its  use.  A  certain  degre  of  tolerance  for  its  action  is  soon 
established  and  if  continued  the  drug  has  to  be  given  in  in- 
creasing doses.  In  all  cases  of  cardiac  disease  it  is  contra- 
indicated. 

Sulfonal  is  often  useful  in  the  treatment  of  cases  of  aliena- 
tion. The  disadvantages  attending  its  use  are  that  it  is  slowly 
absorbed  and  the  hypnotic  effect  is  delayed.     In  spite  of  these 


164  PSYCHIATRY 

objections,  it  may  be  most  successfully  used  for  the  treatment 
of  insomnia,  and  may  also  be  administered  in  many  of  the 
milder  forms  of  excitement.  The  dose  varies  from  10  to  30 
grains.  A  number  of  observers  have  reported  haematopor- 
phyrinuria  as  well  as  excessive  mental  cloudiness  and  occasional 
attacks  of  prostration  with  slight  irregularity  in  the  heart's 
action.  Trional  given  in  doses  of  from  10  to  25  grains  (1  to 
2  grammes)  is  often  efficacious  in  the  same  class  of  cases  in 
which  the  administration  of  sulfonal  is  indicated.  The  hyp- 
notic effect  is  less  delayed,  but  undesirable  symptoms  similar  to 
those  mentioned  in  connection  with  sulfonal  have  been  re- 
corded. 

Choralamide  has  frequently  been  recommended,  but  has 
no  advantages  over  the  drugs  already  mentioned. 

With  the  single  exception  of  the  thyroid  extract  in  cases 
of  myxcedema  and  cretinism,  to  which  reference  is  made  later 
on,  the  various  organic  extracts  have  not  proved  efficacious. 
Among  other  therapeutic  procedures  that  have  been  tried  and 
found  wanting  is  the  use  of  various  substances  which  normally 
set  up  a  febrile  reaction,  in  the  form  of  strong  inunctions, 
blisters,  and  injections.  These  measures  were  based  on  the 
theory  that  the  occurrence  of  fever  frequently  seemed  to  be 
followed  by  a  disappearance  of  some,  if  not  all,  of  the  mental 
symptoms.  Without  going  so  far  as  to  say  that  they  never  do 
good,  mention  may  be  made  of  the  fact  that  many  persons 
suffering  from  alienation  not  infrequently  have  high  tempera- 
tures without  deriving  any  apparent  benefit,  and  even  at  times 
show  an  actual  increase  in  the  severity  of  their  former  symp- 
toms. Equally  unsatisfactory  have  been  the  results  obtained 
by  Binswanger  and  others  who  injected  the  toxins  formed 
by  certain  bacteria,  the  colon  bacillus,  typhoid  bacillus,  etc. 

Saline  infusions,  however,  have  proved  to  be  of  definite 
value  in  the  treatment  of  various  psychoses,  particularly  the 
marked  toxaemia  associated  with  febrile  forms,  acute  delirium, 
amentia,  and  the  more  acute  phases  of  general  paresis.  "    They 

11  Donath,  Julius :    Die  Behandlung  der  progressiven  Paralyse,  sowie 
toxischer  und  infectioser  Psychosen  mit  Salzinfusionen.     Allg.  Ztschr.  f. 


GENERAL   TREATMENT  165 

were  first  recommended  in  1890  by  Sahli  in  cases  of  uraemia 
and  in  collapse.  Various  formulae  have  been  used,  but  the  one 
most  generally  employed  is  the  0.7  per  cent,  physiological  salt 
solution.  If  necessary,  duboisin,  hyoscin,  or  other  medica- 
ments may  be  added  to  it.  From  400  to  800  cubic  centimetres 
are  generally  given,  according  to  the  indications,  at  intervals  of 
from  36  or  48  hours.  Some  clinicians  give  even  larger  quan- 
tities, as  much  as  1000  cubic  centimetres,  and  at  shorter  in- 
tervals.    Donath  highly  recommends  the  following  formula: 

Potassii  sulphat,  0.25  gm.   (gr.  iv)  ; 

Potassii  chloridi,  1.00  (gr.  xvi)  ; 

Natrii  chloridi,  6.75   (gr.  ex)  ; 

Potassii  carbonat.  pur.  sice,  0.40   (gr.  vi)  ; 

Natrii  phosphat.  crys.,  3.10  (gr.  1)  ; 

Aq.  destillat.,  1000  (1  quart). 

The  following  method  of  administration  is  recommended  : 
The  fluid  is  sterilized  in  a  two-litre  glass  vessel  placed  inside 
a  second  larger  vessel  full  of  water,  which  is  then  boiled  for 
from  half  to  three-quarters  of  an  hour  and  allowed  to  cool  to 
400  C.  The  injection,  under  strict  aseptic  precautions,  is  made 
into  the  subcutaneous  tissues  in  the  neighborhood  of  the  breast, 
hypochondrium,  or  beneath  the  skin  of  the  abdomen,  or,  as 
other  authorities  prefer,  directly  into  the  venous  circulation, 
although  it  would  not  appear  that  there  exist  any  special  indica- 
tions for  the  latter  procedure.  Not  infrequently  a  considerable 
rise  in  temperature  is  noted,  but  further  than  this,  if  the  injec- 
tion is  properly  given,  there  are  no  untoward  results.  A  dif- 
ference of  opinion  still  exists  regarding  the  class  of  cases  in 
which  saline  infusions  do  the  most  good.  They  are  strongly 
indicated  in  all  toxic  conditions  where  there  is  motor  restless- 
ness, but  conditions  in  which  mental  depression  is  marked  do 
not  seem  to  be  benefited  by  this  procedure,  and  in  some  instances 
it  has  been  followed  by  a  temporary  increase  in  the  severity  of 

psych,  gericht.  Med.,  Bd.  60,  H.  4,  Berlin,  1903.  Di  Gaspero,  H. :  Ueber 
die  Kochsalzinfusionstherapie  bei  Geisteskranken.  Therap.  d.  Gegenw., 
1902,  S.  397  ff .  Wickel,  C. :  Kochsalzinfusionen  in  der  Therapie  der  Psy- 
chosen.     Psych. -Neurol.  Wchnschr.,  1903,  18,  19. 


1 66  PSYCHIATRY 

the  mental  symptoms.  Soon  after  the  injection  of  the  fluid 
there  is  a  marked  increase  in  the  quantity  of  urine  excreted. 
When,  for  various  reasons,  it  does  not  seem  advisable  to  give 
the  fluid  hypodermically,  high  rectal  injections  of  salt  solution 
may  be  substituted. 

What  has  been  said  so  far  in  regard  to  treatment  applies 
chiefly  to  what  may  be  done  for  patients  in  modern  hospitals 
reserved  for  the  more  acute  types  of  mental  alienation.  As 
soon  as  the  chronic  stage  of  the  disorder  is  reached,  such  indi- 
viduals are  better  off  in  an  asylum  situated  at  some  distance 
from  the  city.  Here  the  patients  can  find  better  opportunities 
for  employment  both  indoors  and  out,  and  at  the  same  time 
they  are  not  brought  into  contact  with  the  more  acute  forms 
of  alienation — a  matter  of  great  importance  for  both  classes 
of  patients.  Much  has  been  written  about  the  home  treat- 
ment of  cases  of  alienation.  Provided  the  patients  have  first 
been  under  the  observation  of  a  thoroughly  competent  alienist 
for  a  time  sufficient  to  allow  him  to  make  a  diagnosis  and 
determine  that  the  sufferer  may,  with  safety  to  himself  and 
his  relatives,  be  given  a  considerable  amount  of  freedom,  it 
is  possible  to  carry  out  the  treatment  along  certain  lines  at 
home,  particularly  if  the  general  practitioner  under  whose 
charge  the  patient  falls  is  willing  to  utilize  the  various  sugges- 
tions which  should  be  given  him.  But  until  a  positive  diagnosis 
has  been  arrived  at,  no  case  of  alienation  should  be  treated  out- 
side of  an  institution.  During  the  remissions  that  occur  in 
cases  of  dementia  prsecox  and  general  paresis  and  in  a  few 
instances  during  the  period  of  convalescence  from  the  acute 
psychoses  the  patient  may  be  allowed  to  remain  at  home,  pro- 
vided that  a  suitable  environment  can  be  maintained  for  him 
there 


CHAPTER   VI 
i 

THE    MODERN    HOSPITAL    FOR    THE    INSANE * 

The  rapid  increase  in  insanity  that  has  followed  the  fever- 
ish activity  in  the  last  few  decades  is  ever  bringing  up  for 
solution  new  problems  dealing  with  the  adequate  provision  of 
suitable  institutions  for  persons  who  have  been  unable  to  bear 
up  against  the  stress,  and  who  have  consequently  become  inca- 
pable of  caring  for  themselves,  or,  still  worse,  who  are  a  men- 
ace to  the  peace  and  welfare  of  those  about  them.  Nor  can 
we  sit  down  with  folded  hands  and  point  with  pride  to  what 
has  already  been  accomplished.  It  is  true  that  among  our  pre- 
decessors, and  even  among  those  who  are  still  living,  it  is  not 
hard  to  find  "  makers  of  history,"  men  preeminent  in  sterling 
character  and  energy,  single-hearted,  with  one  ruling  idea  and 
aim  in  life — to  rescue  the  insane  and  feeble-minded  from 
neglect  or  even  cruelty;  nor  can  we  ever  forget  the  debt  of 
gratitude  we  owe  them.  But  with  changed  times  come  changed 
conditions,  and  progress  is  ever  calling  for  renewed  and  steady 
effort  until  we  shall  have  come  much  nearer  to  perfection  than 
we  are  at  present. 

Broadly  speaking,  the  insane  for  whom  public  care  has  to 
be  provided  may  be  divided  into  three  classes,  of  which,  how- 
ever, numerous  subdivisions  are  possible: 

I.  Those  requiring  constant  care,  supervision,  and  the 
best  possible  medical  treatment,  either  because  (a)  they  are  in 
an  acute  stage  of  mental  disease  and  are  violent  and  dangerous 


1  Griesinger :  Archiv  f.  Psych.,  Berlin,  1868-9.  Transl.  by  Frank  R. 
Smith,  Am.  Journ.  Insan.,  1903,  vol.  lx.  Kraepelin :  The  Duties  of  the 
State  in  the  Care  of  the  Insane.  Transl.  by  Stewart  Paton,  Am.  Journ. 
Insan.,  vol.  lvii,  1901.  Peterson,  F. :  A  Visit  to  the  Newest  Psychopathic 
Hospital.  Med.  News,  vol.  lxxvi,  1900.  Mitchell,  S.  Weir :  Address  be- 
fore the  fiftieth  annual  meeting  of  the  Am.  Med. -Psychol.  Association. 
Proc.  of  Am.  Med. -Psychol.  Association,  Phila.,  1894. 

167 


1 68  PSYCHIATRY 

to  themselves  or  their  fellowmen,  or  (b)  they  are  in  an  incipi- 
ent and  presumably  curable  stage  of  insanity  and  require  special 
and  immediate  attention  in  order  that  their  chances  for  recov- 
ery may  be  materially,  increased. 

II.  Those  requiring  less  constant  care  and  supervision, 
but  who,  nevertheless,  are  fitted  only  for  institution  life  (in 
asylums  or  sanitaria.) 

III.  Those  who,  although  not  capable  of  taking  care  of 
themselves,  are  able  to  live  in  farm  colonies  or  in  private  fami- 
lies. 

The  progress  referred  to  above  has  mainly  affected  the 
last  two  classes.  To  a  large  extent  these  patients  are  insured 
a  comfortable  existence,  and  recoveries  among  them — at  least, 
sufficient  to  warrant  a  return  to  their  homes — are  happily  not 
so  very  rare.  But  in  order  that  we  may  be  able  to  strike  at 
the  root  of  the  matter  we  must  devote  our  best  efforts  ( I )  to 
curing  all  recoverable  cases — and  this  can  be  done  only  by 
taking  them  in  hand  at  the  earliest  possible  moment,  when  the 
disorder  is  still  in  its  incipient  stage;  and  (2)  to  giving  to  as 
many  physicians  as  possible  the  chance  of  receiving  a  thorough 
training  in  psychiatry,  in  order  that  cases  of  insanity  may  be 
recognized  by  the  general  practitioner  before  it  is  too  late,  and 
that  the  importance  of  preventive  psychiatry  may  be  fully 
realized  by  the  leaders  of  thought  in  every  community. 

These  two  fundamental  needs,  then,  since  they  can  not  be 
satisfied  by  the  asylum,  the  farm  colony,  and  the  boarding-out 
system,  call  for  the  establishment  of  special  institutions  which 
have  been  variously  designated  as  hospitals  for  the  insane, 
psychiatrical  clinics,  or  psychopathic  hospitals;  and  these  will 
form  the  subject  of  the  present  chapter. 

Unfortunately,  institutions  that  promise  the  realization 
of  these  ideals  are  too  rarely  found  either  in  Great  Britain  or 
the  United  States.  That  the  need  for  them  has  been  felt  is 
evident  from  the  efforts  that  have  been  made  to  transform 
some  of  the  smaller  asylums  into  psychiatrical  clinics.  Nor 
is  it  to  be  wondered  at  that  such  endeavors  have  proved  only 
partially  successful,  inasmuch  as  the  former  had  been  planned 


PSYCHIATRICAL   HOSPITALS  169 

at  a  time  when  the  present  exigencies  in  the  care  of  the  insane 
either  did  not  exist  or  were  unrecognized.  As  a  result,  these 
transformed  institutions — situated  for  the  most  part  far  from 
the  centres  of  population  and  hampered  by  a  general  arrange- 
ment that  worked  against  the  ready  admission  of  patients, 
while  rendering  instruction  to  students  in  psychiatry  impossi- 
ble— could  never  represent  anything  more  than  a  transition 
stage — a  compromise  between  the  asylum  proper  and  the  real 
hospital.  The  former,  placed  at  some  distance  from  the  city 
and  with  accommodations  for  a  relatively  large  number  of 
patients — from  200  to  1000  or  even  2500 — can  with  proper 
forethought  afford  the  best  care  possible  for  the  chronic  in- 
sane— the  indications  for  progress  being  along  the  lines  of 
improvement  in  hygienic  surroundings  and  facilities  for  light 
employment  in  shops  or  in  the  open  air.  In  these  communities, 
however,  hospital  treatment  must  necessarily  always  be  a  sec- 
ondary consideration,  nor  should  they  be  hampered  by  having 
thrust  upon  them  burdens  and  responsibilities  which  they  are 
not  adapted  to  meet. 

To  restate  the  proposition,  then,  the  psychiatrical  clinic 
or  hospital  is  intended  to  satisfy  two  fundamental  needs  :  ( 1 ) 
Better  provision  for  the  care  and  cure,  if  possible,  of  cases  of 
acute  and  incipient  insanity;  (2)  adequate  provision  for  in- 
struction in  treatment  and  for  investigation  into  problems 
upon  the  solution  of  which  depend  the  arrest  of  the  develop- 
ment of  insanity  in  the  State.  But  in  order  to  fulfil  these  ob- 
jects, its  structure  and  organization  must  be  planned  so  that 
the  following  conditions  will  be  satisfied : 

( 1 )  Ease  of  access.  The  institution  should  be  near  to 
or  within  the  limits  of  a  city. 

(2)  A  limited  capacity,  in  order  that  every  individual 
patient  may  be  made  the  subject  of  special  study. 

(3)  Perfect  construction,  equipment,  and  organization,  in 
order  that  a  thorough  and  energetic  treatment  can  be  under- 
taken for  all  patients  for  whom  there  is  hope  of  recovery. 

(4)  A  relatively  large  staff  of  physicians  and  nurses. 

(5)  Ample  provision  not  only  for  the  teaching  of  stu- 


170 


PSYCHIATRY 


dents,  but  also  for  the  prosecution  of  post-graduate  investi- 
gations and  research  in  clinical  psychiatry,  psycho-pathology, 
and  in  the  anatomy  and  pathology  of  the  nervous  system. 

(6)  The  ready  admission  of  patients  and  their  speedy 
transference,  when  necessary,  to  other  more  appropriate  insti- 
tutions.    Provision  for  out-door  and  voluntary  patients. 

The  manner  in  which,  so  far  as  our  present  experience  has 
taught  us,  these  conditions  may  best  be  met  and  fulfilled  will 
now  be  briefly  discussed. 

( 1 )  Location. — If  the  institution  be  located  at  some  dis- 
tance from  a  centre  of  population,  the  commitment  of  cases  of 
incipient  insanity  will  be  rendered  more  difficult  and  not  a  few 
patients  will  lose  the  opportunity  for  speedy  treatment — which 
in  some  cases  is  equivalent  to  missing  their  only  chance  for 
recovery. 

Of  course,  ideal  conditions  can  not  always  be  realized,  but, 
if  possible,  the  psychiatrical  hospital  should  be  within  the  city 
limits  or  quite  near  them.  The  extensive  grounds,  large  gar- 
dens or  farm,  so  essential  for  the  asylum  or  the  convalescent 
home,  are  not  needed  for  the  hospital,  although  a  certain  area 
of  ground — from  one  to  three  acres — is  indispensable.  This 
would  supply  sufficient  space  for  a  small  garden  where  the  con- 
valescent patients  could  sit  or  walk  in  the  open  air.  Again, 
the  easier  of  access  the  institution  is  to  a  fairly  large  cen- 
tre of  population,  the  less  will  be  the  antipathy  of  patients 
towards  a  residence  there,  since  they  will  feel  that  they  are 
not  shut  up  in  some  remote  asylum  away  from  the  world  and 
all  their  friends ;  and,  moreover,  they  will  be  spared  a  long 
and  tedious  journey,  which  is  distressing  alike  to  patients  and 
relatives. 

Such  an  institution,  when  situated  in  a  city,  will  afford 
the  medical  profession  an  opportunity  of  becoming  as  inti- 
mately acquainted  with  its  organization,  its  methods,  and  its 
results  as  is  the  case  with  the  medical  hospital;  while  at  the 
same  time  the  medical  staff  will  not  be  isolated  and  will  have 
every  chance  of  keeping  in  touch  with  the  advances  that  are 
being  made  in  general  medicine,  of  which  their  own  is  a  most 


PSYCHIATRICAL   HOSPITALS  171 

important  branch.  Again,  the  mere  enumeration  of  the  prob- 
lems to  be  solved,  involving  questions  in  heredity,  the  psycho- 
logical analyses  of  symptoms,  the  chemical  study  of  secretions 
and  excretions,  improvements  in  methods  of  physical  diagnosis, 
ought  to  be  sufficient  to  emphasize  the  necessity  of  placing 
these  psychiatrical  hospitals  in  immediate  proximity  not  only 
to  other  medical  clinics,  but  also  to  the  non-medical  parts  of 
the  university.  The  highest  types  of  clinical  and  laboratory 
investigation  can  only  be  accomplished  in  hospitals  that  are 
sufficiently  close  to  a  good  university  for  the  medical  officers 
to  feel  the  stimulating  effect  of  the  encouragement  and  aid 
given  to  all  forms  of  investigation ;  nor  is  it  probable  that  high 
ideals  in  the  character  of  the  work  to  be  accomplished  will  be 
as  readily  sustained  under  other  conditions. 

(2)  A  Limited  Capacity. — The  capacity  of  the  hospital 
must  naturally  depend  much  upon  the  demands  of  the  com- 
munity in  which  it  is  situated.  It  is  advisable,  however,  that 
it  should  be  relatively  small,  so  that  each  individual  case  can 
be  studied  carefully  in  a  reasonably  short  time.  In  asylums  for 
chronic  patients  there  is  much  less  urgency  in  this  matter,  but 
in  a  case  of  acute  insanity  a  speedy  and  as  far  as  possible  a 
correct  diagnosis  is  most  important,  inasmuch  as  the  future 
of  these  patients  is  in  the  balance.  Roughly  speaking,  insti- 
tutions varying  in  capacity  from  80  to  100  beds  represent 
the  size  which  best  lends  itself  to  an  efficient  organization. 
Furthermore,  the  fact  that  the  accommodations  are  limited 
will  serve  to  prevent  the  accumulation  of  chronic  cases  which 
belong  elsewhere. 

(3)  Construction,  Equipment,  and  Organization. — The 
problems  dealing  with  the  construction  of  such  hospitals  for 
the  insane  have  not  as  yet  received  much  attention  in  English- 
speaking  countries.  Many  of  these  institutions  in  Germany 
are  admirably  adapted  to  meet  the  needs  of  the  several  com- 
munities in  which  they  have  been  established.  But  in  America 
and  England  conditions  are  so  different  that  the  German  ideas 
could  not  be  accepted  without  considerable  modifications  in 
the  general  plans.     With  us  most  of  the  details  have  yet  to 


172 


PSYCHIATRY 


be  worked  out,  but  even  at  the  present  time  a  few  axiomatic 
propositions  are  permissible. 

In  the  first  place,  from  a  technical  stand-point,  in  all  mat- 
ters of  construction,  equipment,  and  organization  such  an 
institution  must  partake  of  the  character  of  a  hospital  as  fully 
as  any  of  the  best  institutions  provided  for  the  care  and  treat- 
ment of  the  so-called  bodily  disorders.  This  at  once  necessi- 
tates the  provision  for  the  treatment  in  bed  of  a  large  percen- 
tage of  the  patients.  Experience  has  taught  us  that  many  suf- 
ferers from  acute  psychoses  or  exacerbations  of  the  more 
chronic  mental  disorders  do  far  better  when  confined  to  bed 
until  the  acute  symptoms  have  passed  off.  Physicians  con- 
nected with  out-patient  departments  every  day  meet  with  indi- 
viduals suffering  from  incipient  insanity,  whom  they  are  unable 
to  benefit  at  their  .homes  because  facilities  for  putting  the 
patients  to  bed,  isolating  them,  and  employing  the  other  neces- 
sary procedures  are  lacking.  In  addition  to  the  various  forms  of 
apparatus  which  naturally  belong  to  a  general  hospital,  the 
institution  should  be  well  provided  with  all  the  appliances 
necessary  for  carrying  out  hydrotherapeutic  measures.  It 
should  also  be  possible  to  give  Turkish  baths,  the  various 
sprays  and  douches,  and  also  the  prolonged  or  continuous 
bath. 

The  institution  should  contain  two  small  reception  de- 
partments (with  separate  accommodations  in  each  for  men 
and  women),  where  new-comers  may  stay  for  a  few  hours, 
until  they  have  been  carefully  examined  and  a  rational  course 
of  treatment  has  been  outlined  for  each  case.  One  department 
should  be  set  apart  for  maniacal  or  delirious  patients  and  the 
other  reserved  for  individuals  who  are  less  noisy  and  are  not 
apt  to  disturb  their  companions.  It  is  very  inadvisable  to  put 
quiet  patients  with  those  who  are  violent,  especially  as  many 
individuals  suffering  from  incipient  insanity  retain  a  fair  in- 
sight into  their  own  condition,  and  nothing  can  have  a  worse 
mental  effect  upon  them  than  to  be  brought  into  close  asso- 
ciation with  pronounced  forms  of  insanity. 

(4)    (a)    The  Medical  Staff. — With  regard  to  the  organi- 


PSYCHIATRICAL    HOSPITALS  173 

zation  of  the  medical  staff,  it  is  quite  evident  that  the  number 
of  physicians  required  will  be  relatively  greater  than  that 
deemed  necessary  for  a  general  hospital.  The  fact  that  the 
examination  of  an  average  insane  patient  takes  two  or  three 
times  as  long  as  when  one  has  to  deal  with  an  ordinary  sick 
man  means  that  a  much  larger  staff  of  physicians  can  find  full 
employment. 

In  this  connection  it  may  be  pointed  out  that  if  the  psycho- 
pathic hospital  is  established  in  close  proximity  to  a  medical 
school  a  great  many  advantages,  not  only  to  the  medical  staff 
but  also  to  the  patients,  may  be  obtained  from  the  employment 
of  "  voluntary  assistants."  Young  graduates  or  medical  stu- 
dents accepting  these  positions  and  working  for  a  few  hours 
every  day  can  easily  be  trained  in  taking  histories  and  assisting 
in  examinations  with  great  benefit  to  themselves,  while  at  the 
same  time  they  can  relieve  the  members  of  the  medical  staff 
from  much  of  the  dull  routine  which  otherwise  would  fall  on 
them  and  become  so  burdensome  that  it  might  deaden  their 
interests  in  the  higher  problems  connected  with  their  pro- 
fession. 

The  sole  responsibility  of  the  clinic  must  rest  upon  the 
medical  director,  who  should  be  in  absolute  control  of  all  medi- 
cal matters,  and  who  should  have  a  continuous  and  not  an  inter- 
rupted service.  The  inferior  character  of  the  work  accom- 
plished in  the  general  medical  hospital,  where  one  physician 
attends  for  a  few  months  and  is  then  followed  by  another,  as 
compared  with  that  done  where  a  single  head  is  responsible  for 
the  whole  service  year  in  and  year  out,  should  be  a  sufficient 
argument  against  the  establishment  of  the  rotation  method  in 
connection  with  our  hospitals  for  the  insane. 

It  is  advisable  that  the  management  of  the  institution 
should  be  under  the  ultimate  control  of  the  university  authori- 
ties, the  director  being  a  member  of  the  medical  faculty. 

The  department  of  psychiatry  may  justly  be  considered 
one  of  the  most  important  in  a  university,  and  the  directorship 
of  the  hospital  and  the  professorship  of  psychiatry  should  be 
held  by  one  and  the  same  man,  who  should  receive  a  remunera- 


i74  PSYCHIATRY 

tion  sufficiently  large  to  entirely  relieve  him  of  the  necessity 
of  seeking  outside  practice. 

The  examination  of  the  patients,  the  general  direction  of 
the  medical  work,  the  supervision  of  investigations  carried  on 
by  competent  assistants  in  the  laboratory,  and  the  training  of 
students — undergraduates  and  postgraduates — will  be  more 
than  sufficient  to  occupy  the  attention  of  the  chief  medical 
officer.  If  the  medical  work  is  to  be  successfully  organized 
and  carried  on,  it  is  essential  that  the  assistants  and  students 
be  stimulated  and  encouraged  by  the  example  set  by  the  direc- 
tor in  undertaking  and  carrying  out  original  investigation,  and 
in  view  of  the  difficulties  connected  with  the  clinical  and  labo- 
ratory problems  with  which  he  has  to  grapple,  sufficient  time 
for  study  and  investigation  should  be  allowed  him. 

It  is  far  better  that  the  director  should  not  live  in  the 
hospital.  During  the  night  and  for  the  few  hours  of  the  day 
during  which  he  is  absent  his  place  can  perfectly  well  be  taken 
by  the  first  assistant.  This  officer,  whose  duties  should  be 
regulated  by  the  director,  whenever  it  is  possible,  should  be  a 
comparatively  young  man,  who.  is  thoroughly  interested  in 
his  subject  and  for  the  sake  of  the  valuable  experience  that 
such  a  position  carries  with  it  is  willing  to  spend  at  least  two 
years  in  the  service  of  the  institution.  It  is  readily  seen  that 
too  many  changes  would  be  unjust  not  only  to  the  patients, 
but  also  to  the  director,  since  the  resident,  when  he  has  once 
become  familiarized  with  his  duties,  can  not  only  take  better 
care  of  the  former,  but  can  also  relieve  the  latter  of  many  of 
the  responsibilities  connected  with  the  clinic  and  the  supervision 
of  the  work  that  is  being  done  in  the  laboratory. 

It  would  be  an  ideal  arrangement  if  the  interests  of  the 
first  assistant  were  directed  along  lines  different  from  those 
of  the  second  assistant,  in  order  that  the  whole  field  of  psychi- 
atry might  as  far  as  possible  be  represented,  at  least  in  the 
interests  of  the  staff.  Thus,  if  one  assistant  shows  a  preference 
for  the  pathological  problems,  it  would  be  well  if  one  or  more 
of  the  others  were  to  take  up  more  especially  psychological, 
physiological,  and  chemical  studies. 


PSYCHIATRICAL    HOSPITALS  175 

On  the  whole,  it  would  seem  better  that  the  responsibility 
for  the  male  and  female  wards  should  rest  upon  one  individual 
and  that  two  assistants  should  never  have  equal  authority.  In 
a  hospital  with  accommodations  for  100  patients,  in  addition 
to  two  resident  physicians,  it  would  be  advisable  to  have  one 
or  more  graduates  as  clinical  assistants,  who  could  receive 
their  board  and  lodging  but  would  be  willing  to  work  without 
a  salary.  Again,  as  has  been  said  before,  much  of  the  routine 
work  could  be  done  by  students. 

(b)  The  Nursing  Staff. — As  in  the  case  of  the  medical 
staff,  the  conditions  existing  in  a  general  hospital  are  not  to 
be  taken  as  an  index  of  the  number  of  nurses  that  is  necessary 
for  the  psychiatrical  clinic.  For  several  reasons  a  relatively 
much  larger  number  is  required  in  the  latter.  In  the  first 
place,  very  few  of  the  patients  are  capable  of  aiding  in  the 
carrying  out  of  the  treatment,  and  others,  actively  or  passively, 
resist  any  form  of  interference.  Besides  this,  more  particu- 
larly in  a  hospital  for  cases  of  acute  insanity,  a  large  majority 
of  the  patients  have  to  be  carefully  watched  every  moment, 
lest  a  sudden  impulse  should  lead  them  to  commit  some  act  of 
violence  and  to  inflict  an  injury  either  upon  themselves  or  upon 
those  around  them.  When  these  facts  are  taken  into  considera- 
tion, it  becomes  at  once  apparent  with  what  great  mental,  in 
addition  to  physical,  strain  the  duties  of  the  nurse  are  associ- 
ated. Moreover,  for  the  same  reason,  the  hours  of  duty  in 
the  wards  should  undoubtedly  be  short,  otherwise  the  nurse 
cannot  fail  to  lose  much  of  the  mental  freshness  and  vigor  so 
essential  in  dealing  properly  with  the  insane. 

The  organization  of  the  nursing  staff  could  be  safely  in- 
trusted to  a  superintendent  who  has  already  had  some  practice 
in  the  education  and  training  of  nurses  in  a  good  general  hos- 
pital and  has  afterwards  had  some  practical  experience  in  the 
care  of  the  insane.  The  latter  would  also  be  highly  desirable 
in  the  case  of  a  certain  proportion,  at  least,  of  the  head  nurses. 

(5)  Facilities  for  Teaching  and  Investigation. — It  is 
always  a  matter  of  surprise  to  visiting  Americans  to  see  the 
large  sums  of  money  that  have  been  and  are  being  expended  in 


176  PSYCHIATRY 

Germany  for  building  and  equipping  laboratories — patholog- 
ical, physiological,  and  chemical — in  connection  with  psychi- 
atrical clinics.  The  amount  of  expenditure  justifiable  in  the 
several  cases  necessarily  depends  upon  a  variety  of  conditions. 
For  example,  if  the  psychiatrical  clinic  is  in  close  proximity  to 
some  good  medical  school  or  university,  the  laboratory  space 
can  be  readily  confined  to  two  or  three  medium-sized  rooms, 
in  which  a  few  students  can  work,  since  abundant  facilities 
can  be  afforded  to  the  members  of  the  staff  and  special  investi- 
gators in  some  of  the  other  buildings — the  anatomical,  patho- 
logical, or  physiological  laboratories.  If,  however,  the  insti- 
tution is  situated  at  some  distance  from  a  centre,  so  that  these 
conveniences  are  not  available,  much  larger  sums  will  have  to 
be  spent  in  providing  separate  and  commodious  laboratories. 

(6)  The  Admission  and  Transfer  of  Patients. — For  the 
benefit  of  the  patients,  admission  into  these  hospitals  should 
be  made  as  easy  as  possible,  and  there  should  be  a  minimum 
amount  of  formality  and  red  tape.  Elaborate  legal  procedures 
can  not  fail  to  deter  many  patients  from  availing  themselves  in 
time  of  the  immense  benefits  offered  to  them  and  their  families 
by  such  institutions.  In  our  day  and  generation  the  argument 
that,  if  certain  long-established  forms  are  done  away  with, 
many  sane  persons  will  be  liable  to  detention  in  institutions 
against  their  will,  is  too  ridiculous  to  deserve  serious  consid- 
eration. To  render  such  an  outrage  possible,  the  conspiracy — 
between  the  medical  officers  and  nurses,  and  even  servants  of 
the  institution,  who  would  have  to  be  in  league  with  the  com- 
mitting physicians  and  the  patient's  friends — would  be  so  com- 
plicated and  require  such  wide  ramifications  that  it  would  only 
be  a  matter  of  a  few  hours  or  days  before  the  news  of  the  de- 
tention would  be  spread  abroad  and  reach  the  ears  of  the  mem- 
bers of  the  State  Board  of  Lunacy  and  the  public. 

Voluntary  Patients. — An  individual  who  is  conscious  that 
his  mental  condition  renders  it  unsafe  for  him  to  remain  at 
large  should  readily  be  able  to  obtain  admission  into  the  hos- 
pital until  a  careful  examination  can  be  made  into  his  condi- 
tion.   If,  however,  on  mature  consideration  it  becomes  apparent 


PSYCHIATRICAL    HOSPITALS  177 

to  the  medical  officer  that  the  patient  can  not  be  trusted  or  that 
he  will  probably  later  object  to  remain  until  he  has  sufficiently 
recovered  to  warrant  his  discharge,  the  friends  should  at  once 
be  advised  of  the  matter,  so  that  a  formal  commitment  can  be 
made. 

Out-Door  Patients. — In  connection  with  the  hospital  a 
well-organized  dispensary  or  department  for  out-door  patients 
is  an  essential  supplement  to  the  hospital  proper.  In  all  our 
large  cities  patients  come  every  day  to  the  neurological  clinics 
who  are  on  the  border  line  of  insanity,  although  their  closest 
relatives  may  never  have  suspected  the  existence  of  any  mental 
defect.  Such  patients  could  be  kept  under  observation  in  the 
out-door  clinic  and  could  at  once  be  committed,  if  necessity 
arose,  to  the  hospital  itself.  Moreover,  on  being  discharged 
from  the  hospital,  patients  could  be  told  to  report  at  the  dis- 
pensary at  stated  intervals,  and  thus  be  kept  under  observation 
for  a  length  of  time  sufficient  to  satisfy  the  physician  how  far 
the  recovery  has  proceeded. 

It  is  evident  that  all  patients  who,  after  careful  exami- 
nation, are  found  not  to  be  of  the  class  for  which  the  psychi- 
atrical hospitals  have  been  established  or  who  are  evidently 
passing  into  a  chronic  stage  of  insanity  should  immediately  be 
transferred  to  other  more  appropriate  institutions. 

Briefly,  then,  the  economic  advantages  to  a  community 
of  a  psychiatrical  hospital  with  a  well-organized  out-patient 
department  may  be  summed  up  as  follows : 

( 1 )  A  large  number  of  patients  would  receive  the  benefit 
of  skilled  medical  care  at  a  stage  of  the  disease  at  which  there 
is  great  hope  of  either  aborting  or  cutting  short  an  attack  of 
insanity.  Thus  there  would  be  an  actual  decrease  in  the  num- 
ber of  insane  individuals. 

(2)  Numerous  fatalities — suicides  and  homicides — would 
be  prevented  by  the  timely  commitment  of  individuals  suffer- 
ing from  acute  attacks  of  insanity. 

(3)  The  asylums  proper,  in  contradistinction  to  psychiat- 
rical hospitals,  would  be  relieved  of  many  of  the  more  trouble- 
some cases  and  would,  therefore,  be  much  better  fitted  to  carry 
out  their  appropriate  work. 


CHAPTER  VII 

GENERAL  CAUSES  OF  INSANITY 

The  study  of  the  etiology  of  mental  disease  is  bound  up 
with  that  of  the  most  difficult  problems  in  medicine.  The  in- 
vestigator, as  a  rule,  does  not  have  to  deal  with  causes  which 
are  immediately  operative,  but  rather  with  those  whose  action 
is  delayed  and  prolonged,  it  may  be,  over  a  number  of  years. 
Frequently  the  individual  does  not  come  under  observation 
until  the  original  cause  has  ceased  to  operate  and  a  condition 
so  complex  has  developed  that  it  is  impossible  to  determine  the 
essential  factor  or  factors  in  the  etiology.  Unfortunately,  the 
study  of  the  mental  functions  of  the  normal  individual  has  not 
been  of  the  character  to  be  of  great  aid  to  the  alienist  in 
attempting  to  analyze  the  disturbances  grouped  as  insanity. 
As  has  frequently  been  pointed  out,  clinical  observations  have 
been  largefy  isolated  and  disconnected,  so  that  no  standards 
exist  by  which  comparison  can  be  made  and  early  deviations 
from  the  normal  mentality  detected.  Furthermore,  the  transi- 
tion from  the  normal  to  the  abnormal  in  the  mental  life,  except 
in  isolated  cases,  is  slow  in  its  progression ;  and  even  in  these 
latter  instances  it  is  still  a  matter  of  doubt  whether  a  given 
individual,  who  has  been  perfectly  normal  mentally,  as  a  result 
of  some  accident  can  suddenly  become  afflicted  with  a  definite 
alienation.  In  the  etiology  of  mental  diseases,  then,  we  have 
to  do  with  an  exaggeration  of  personal  idiosyncrasies,  with 
the  accentuation  of  abnormal  traits  in  character,  and  with  a 
more  or  less  complete  dissociation  of  the  entire  personality. 
How  far  the  modifications  which  take  place  in  the  individual 
in  alienation  are  due  to  external  and  how  far  to  internal  causes 
it  is  well-nigh  impossible  to  say.  To  be  able  to  determine  the 
operative  cause  in  any  case  of  alienation  implies  the  possession 
of  some  knowledge  regarding  the  exact  nature  of  the  transition 

178 


CAUSES    OF   INSANITY  179 

that  takes  place  in  the  patient  when  he  passes  from  the  actual 
world  to  the  world  of  imagination  in  which  the  insane  person 
lives.1  Concerning  the  nature  of  this  change  we  have  no 
knowledge.  This  one  fact,  however,  is  obvious,  that  the  vari- 
ety of  fluctuations  in  the  normal  mental  life  is  strongly  con- 
trasted with  the  more  or  less  monotonous  character  of  the  men- 
tal processes  in  those  who  are  insane. 

Again,  in  many  instances,  to  attain  a  comprehensive  knowl- 
edge of  the  development  of  a  case  of  alienation  would  neces- 
sitate not  only  a  study  of  causes,  but  an  insight  into  the  char- 
acter and  temperament  of  the  individual  prior  to  the  appearance 
of  the  mental  symptoms.  Every  psychosis  begins  with  a 
change  in  sensation,  temperament,  or  representation  that  af- 
fects the  relation  of  the  individual  to  his  environment.  What 
the  earliest  changes  are  can  as  yet  be  only  vaguely  conjectured. 
A  rich  reward  awaits  the  clinician  who  will  patiently  study 
the  earliest  symptoms  of  imperfect  functioning  of  the  cerebral 
cortex  as  they  appear  in  connection  with  the  slight  changes  in 
function  of  many  of  the  internal  organs.  As  we  are  still  in 
ignorance  as  to  the  precise  manner  in  which  causes  operate, 
the  view  of  Mobius,  that  mental  diseases  should  be  classed  as 
endogenous  or  exogenous,  or  that  of  Kraepelin,  that  we  should 
speak  of  internal  or  external  causes,  although  suggestive,  does 
not  aid  materially  in  the  solution  of  the  problems. 

Heredity. — There  is  so  much  glib  talk  about  the  prob- 
lems of  heredity  that  the  uninitiated  are  led  to  believe  that  a 
great  deal  is  definitely  known  regarding  the  transmission  of 
normal  and  abnormal  mental  traits ;  indeed,  many  alienists 
fail  to  appreciate  our  limitations  in  this  respect.  At  present 
we  do  not  possess  an  accumulation  of  carefully  collected  clini- 
cal data  from  which  it  is  justifiable  to  draw  any  really  valuable 
deductions,  nor  can  the  meagre  facts  recorded  in  the  average 
clinical  history  be  analyzed  in  such  a  way  as  to  make  clear 
their  bearing  upon  the  biological  problems  under  discussion. 

1  Tiling,  Th. :    Zur  Aetiologie  der  Geistesstorungen.     Centralbl.  f.  Ner- 
venheilk.  u.  Psych.,  1903,  September,  Bd.  xiv. 


180  PSYCHIATRY 

Moreover,  a  little  practical  experience  will  readily  convince 
the  investigator  that  the  data  connected  with  the  supposed 
transmission  of  mental  traits,  that  can  be  gleaned  by  the  alien- 
ist, are  generally  far  too  vague  to  merit  serious  consideration. 
No  doubt,  inquiries  concerning  the  mental  traits  and  charac- 
teristics of  the  ancestors  of  those  afflicted  with  alienation  often 
bring  to  light  interesting  information  about  the  environment 
in  which  the  patient  has  been  born  and  brought  up,  but  any 
attempt  to  deduce  therefrom  conclusions  as  to  the  quality  or 
quantity  of  natural  mental  capacity  that  may  be  said  to  be 
transmitted  from  the  individuals  of  one  generation^  to  those  of 
the  next  will  at  once  prove  unsatisfactory.  Such  an  investi- 
gation must  necessarily  deal  with  a  number  of  indefinite  fac- 
tors. What  is  born  with  the  individual?  What  happens  to 
him  after  birth  ? 2  These  are  the  two  main  problems,  in- 
volving many  others,  which  call  for  immediate  solution,  and 
to  obtain  a  satisfactory  answer  to  each  of  these  careful  in- 
vestigations along  many  different  lines  are  necessary.  Broadly 
speaking,  then,  we  distinguish  between  the  so-called  original 
traits  or  inherent  qualities,  that  are  the  result  of  influences 
which  have  acted  prior  to  birth,  and  the  secondary  or  post- 
natal characteristics  that  result  more  immediately  from  en- 
vironment and  education.  It  is  readily  seen  that  essential 
points  in  the  discussion  of  the  first  question  are  hard  to  arrive 
at,  and  the  little  information  obtainable  frequently  comes  to 
us  second-hand  and  is  obscured  by  so  many  other  factors  that 
it  becomes  almost  impossible  to  form  even  a  conjecture  as  to 
what  mental  characteristics  can  be  attributed  to  transmission 
from  the  ancestral  line.  Koller  3  examined  the  family  histories 
of  370  perfectly  sane  individuals  and  found  evidence  of  mental 
deterioration  among  the  progenitors  in  59  per  cent,  of  the 
cases,  whereas  for  370  insane  persons  the  hereditary  factor  was 
present  in  76.8  per  cent.    The  mere  citation  of  these  figures  is 


2  Thorndike,  Edward  L. :     Educational  Psychology.     New  York,  1903. 

3  Koller,  Jenny:    Beitrag  zur  Erblichkeitsstatistik  der  Geisteskranken 
im  Kanton  Zurich,  etc.,  Arch.  f.  Psych.,  xxviii. 


CAUSES    OF    INSANITY  l8l 

sufficient  to  show  how  careful  investigators  should  be  in  basing 
deductions  as  to  the  relative  importance  of  "  a  bad  family  his- 
tory" upon  any  series  of  figures  which  have  not  been  subjected 
to  the  severest  form  of  critical  analysis.  Again,  the  difficulties 
involved  in  the  discussion  of  the  problems  relating  to  the  in- 
heritance of  mental  traits  are  far  more  complex  than  those 
encountered  in  dealing  with  the  transmission  of  mere  physical 
qualities ;  and  they  are  still  further  increased  when  an  attempt 
is  made  to  determine  the  relation  of  these  questions  to  clinical 
problems,  since  in  order  to  arrive  at  any  sound  conclusions  it 
is  first  necessary  to  have  a  clear  understanding  of  the  patho- 
genesis of  the  various  forms  of  insanity,  and,  as  has  been 
pointed  out  elsewhere,  this  latter  field  is  still  unexplored. 

Perhaps  a  concrete  example  may  serve  to  bring  out  some 
of  these  difficulties.  Morgan  4  has  referred  to  the  classical  ex- 
periments of  Brown-Sequard  in  which  epilepsy  appeared  in 
animals  born  of  parents  rendered  epileptic  by  an  injury  to  the 
spinal  cord  or  by  section  of  the  sciatic  nerve.  At  first  thought 
this  evidence  might  seem  to  support  the  Lamarckian  hypothesis 
of  the  inheritance  of  acquired  characteristics,  but,  as  Morgan 
has  pointed  out,  so  little  is  actually  known  about  the  nature  of 
the  disease  in  question  that  it  is  not  justifiable  to  indulge  in 
any  speculation  as  to  the  deductions  that  are  warranted  from 
experiments  of  this  character.  During  uterine  life  so  many 
possible  factors  may  be  operative  that  the  appearance  of  post- 
natal epilepsy  can  not  as  yet  in  any  sense  be  considered  evidence 
of  the  immediate  transmission  of  an  acquired  defect.  Epi- 
lepsy, which  may  very  properly  be  taken  as  a  prototype  of 
alienation,  is  not  in  any  sense  an  entity,  but  a  condition  or 
symptom-complex,  and  may  be  the  result  of  a  great  variety  of 
causes,  and  the  same  is  true  in  regard  to  all  the  various  psy- 
choses which  represent  more  or  less  indefinite  complexes  and 
in  which  the  possible  effects  of  a  multiplicity  of  etiological 
factors  have  to  be  taken  into  consideration.  In  the  description 
of  physical  conditions  we  possess  standards  of  measurement 

4  Evolution  and  Adaptation.     New  York  and  London,  1903. 


1 82  PSYCHIATRY 

which  are  exact  and  which  may  be  stated  in  figures ;  whereas, 
in  the  consideration  of  mental  traits  comparative  estimates  vary 
greatly,  as  the  result  not  only  of  the  personal  equation,  but 
also  of  the  conditions  under  which  the  observations  are  carried 
on.  Even  if  it  were  possible  to  establish  certain  standards  by 
which  the  mental  capacity  of  the  members  of  a  family  could 
be  measured,  the  departures  from  that  standard  could  be  the 
result  of  so  many  different  conditions  that  in  the  final  analysis 
the  observer  would  be  practically  unable  to  put  his  finger  upon 
the  particular  facts  or  factors  concerned.  Take,  for  example, 
a  family  which  for  several  generations  has  resided  in  a  small 
country  town  and  in  which,  as  each  new  generation  has  ap- 
peared, the  same  factors  have  been  operative  in  moulding  the 
mental  and  physical  development  along  certain  lines.  If  now  at 
the  end  of  a  given  time  this  family  removes  to  a  large  city,  or  if 
in  any  way  the  immediate  environment  is  suddenly  changed,  so 
many  exigencies  arise  and  so  many  new  conditions  at  once  be- 
come operative  that  it  is  impossible  to  enumerate  the  agencies 
which  maybe  potent  in  affecting  the  development  of  the  children 
born  in  the  new  environment.  The  same  difficulties  arise  even 
when  the  transmission  of  traits,  not  from  remote  ancestors 
but  directly  from  the  mother  to  the  child,  are  under  discus- 
sion. The  action  of  environmental  influences — anaemias,  toxic 
agents,  and  the  like — can  not  always  be  recognized  and  defi- 
nitely distinguished  from  the  other  forces  affecting  the  life 
of  the  organism.  At  present  the  majority  of  biologists  declare 
that  we  have  no  direct  indubitable  evidence  that  substantiates 
the  Lamarckian  view.  It  only  remains,  then,  for  us  to  confess 
our  practical  ignorance  concerning  the  immediate  problems  con- 
nected with  the  acquisition  of  mental  traits  and  their  trans- 
mission to  a  line  of  descendants,  and  our  inability  to  measure 
with  any  precision  how  far  acquired  conditions  of  general 
health  produce  changes  in  the  germ  plasm  and  to  what  degree 
such  changes  influence  mental  qualities  in  the  offspring. 

The  so-called  personal  predisposition  of  certain  indi- 
viduals towards  mental  disease  is  of  great  practical  interest. 
As  we  have  already  seen,  this  tendency  seems  to  be  the  result 


CAUSES    OF    INSANITY  183 

of  a  number  of  factors  which  at  present  can  not  be  successfully 
interpreted,  although  the  opportunities  for  studying  such  phe- 
nomena are  numerous.  In  pronounced  types  of  the  so-called 
cumulative  or  convergent  hereditary  predisposition  the  physical 
or  mental  degeneracy  is  said  by  some  observers  to  be  found  in 
both  the  paternal  and  the  maternal  ancestry.  In  the  unilateral 
type  the  degeneracy  appears  either  on  the  maternal  or  the  pa- 
ternal side. 

Atavistic  Heredity. — Tanzi  and  Riva  affirm  that  an  ata- 
vistic tendency  is  very  important  in  certain  forms  of  degen- 
eracy, and  becomes  apparent  in  a  marked  predisposition  shown 
by  members  of  a  family  to  outbreaks  of  alienation.  According 
to  these  observers,  in  this  form  certain  signs  of  nervous  or 
psychopathic  degeneracy  have  apparently  persisted  through  a 
number  of  generations  and  have  finally  become  so  accentuated 
that  the  individual  concerned  seems  to  be  reduced  to  the  primi- 
tive state  from  which  the  race  has  shown  a  slow  evolution. 
This  form  of  heredity  has  been  particularly  emphasized  by  the 
anthropologists, — Lombroso  and  others, — and  this  so-called 
cumulative  tendency  is  supposed  to  satisfactorily  account  for 
the  ferocity  of  certain  criminals,  as  well  as  for  the  fact  that 
many  of  these  low  instincts  have  a  tendency  to  become  perma- 
nent in  certain  families.  Another  important  feature  lies  in  the 
fact  that  the  reappearance  of  morbid  traits  in  the  line  of  the 
descendants  may  be  either  simple  or  transformed  (homomor- 
phous  or  heteromorphous).  Thus  when  the  same  form  of 
degeneracy  or  psychosis  appears  it  has  a  tendency  to  recur 
practically  unchanged  in  the  descendants,  whereas  the  trans- 
formed type  is  characterized  by  a  complete  change  in  the  form 
of  the  degeneracy  or  psychosis.  Since  the  days  of  Morel  5  the 
importance  of  the  so-called  hereditary  degeneracy  has  been 
emphasized  by  numerous  investigators.  Morel  himself  holds 
that  the  law  of  transmitted  degeneracy  is  more  or  less  definite 
and  is  capable  of  being  formulated  somewhat  as  follows :    In 

5  Traite  des  degenerescences  physiques,  morales  et  intellectuelles  de 
l'espece  humaine,  1857. 


184  PSYCHIATRY 

the  first  generation  we  have  a  nervous  temperament  and  ethical 
and  moral  defects ;  in  the  second  a  tendency  towards  apoplec- 
tiform seizures,  severe  neuroses,  or  alcoholism;  in  the  third, 
marked  psychic  disturbances,  suicidal  manias,  and  intellectual 
defects;  in  the  fourth,  idiocy,  imbecility,  and  other  anomalies 
in  development  are  noted.  Nevertheless,  it  must  be  said  that 
in  view  of  the  great  complexity  of  the  problems  involved  such 
a  definite  formulation  must  necessarily  be  merely  conjectural. 
Piercani 6  examined  the  family  histories  of  1958  persons, — 1064 
males  and  894  females,  representing  889  families, — and  came 
to  the  following  conclusions :  The  occurrence  of  disease  in  the 
father  or  mother  seemed  to  have  a  more  serious  effect  upon  the 
male  than  upon  the  female  descendants.  The  "  cross-heredity" 
is  apparently  more  marked  between  mother  and  son  than  be- 
tween father  and  daughter.  Wiglesworth  7  examined  2445 
cases  of  mental  disease  with  a  special  view  to  determining  the 
relative  importance  of  the  hereditary  factor,  and  concluded  that 
it  was  present  in  28  per  cent,  of  all  the  cases,  but  was  less  fre- 
quent in  men  than  in  women.  Where  the  mother  had  suffered 
from  alienation,  and  where  there  were  both  sons  and  daughters 
among  the  descendants,  the  latter  were  more  commonly  af- 
fected than  the  former.  Our  own  observations  do  not  confirm 
the  experience  of  other  alienists  that  the  daughters  are  less 
prone  than  the  sons  to  show  signs  of  mental  aberration  when 
the  father  has  been  insane. 

Consanguineous  marriages  are  said  to  be  often  followed 
by  anomalies  in  the  children.  Thus,  in  a  family  observed  by 
Mathieu,8  which  consisted  of  43  descendants  of  parents  who 
were  blood  relatives,  10  were  described  as  "  peculiar,"  3  as 
fools  or  idiots,  3  were  deaf-mutes,  and  1  committed  suicide. 
Howe  studied  95  children,  the  issue  of  consanguineous  mar- 


6  Ulteriore  contribute  alio  studio  delle  leggi  che  regolano  la  ereditaria 
psicopatica.     Atti  dell'  XI  Congresso  freniatr.,  Ancona,  1904. 

7  The  Presidential  Address  delivered  at  the  Sixty-first  Annual  Meeting 
of  the  Medico-Psychological  Association,  held  at  Liverpool  on  July  24,  1902. 
The  Journ.  of  Ment.  Science,  xlviii,  p.  611. 

8  Gaz.  des  Hop.,  1890,  p.  1260. 


CAUSES    OF    INSANITY  185 

riages,  and  found  that  44  were  idiots.  The  world's  history- 
affords  interesting  examples  of  the  importance  of  the  unfor- 
tunate results  that  follow  too  close  and  frequent  intermarriages 
between  relatives. 

The  importance  of  the  hereditary  factor  varies,  not  only 
in  different  countries,  but  also  in  different  races  and  in  different 
social  states.  Thus,  for  example,  its  significance  is  undoubted 
in  aristocratic  circles,  in  classes  where  the  marriages  are  largely 
confined  to  individuals  of  the  same  social  and  intellectual  stand- 
ing, and  among  certain  races  or  sects,  such  as  the  Jews  or 
Quakers.  In  this  connection,  however,  it  has  been  questioned 
whether  the  mere  inbreeding  of  families  in  itself  necessarily 
gives  rise  to  deterioration,  provided  there  is  no  sign  of  degen- 
eracy in  either  of  the  parents. 

The  evidence  respecting  heredity  as  a  factor  varies  greatly, 
but  its  influence  would  appear  to  be  very  pronounced  in  certain 
psychoses,  such  as  alcoholism,  manic-depressive  insanity,  and 
epilepsy,  whereas  in  other  maladies,  such  as  the  arterio- 
sclerotic insanities  and  the  senile  psychoses,  it  is  likely  to  be 
comparatively  unimportant.  As  regards  the  so-called  signs  of 
degeneracy,  it  is  probable  that  alienists,  have  gone  too  far  and 
have  drawn  too  sweeping  deductions,  and  we  are  now  begin- 
ning to  see  that  the  use  of  the  term  needs  to  be  qualified  in  each 
individual  case.  Broadly  speaking,  the  signs  of  degeneracy 
may  be  grouped  under  two  heads :  ( 1 )  the  somatic  and  (2)  the 
psychical.  In  the  first  group  we  meet  with  a  variety  of  mani- 
festations which  indicate  interference  with  development,  and 
are  most  marked  in  the  defect  psychoses.  Among  these  may 
be  mentioned  epileptiform  seizures,  attacks  of  severe  neuralgia, 
a  tendency  to  sexual  and  alcoholic  excesses,  anomalies  of  den- 
tition, intolerance  for  alcohol,  and  various  forms  of  paralysis, 
either  limited  or  more  or  less  general  in  character.  The  vari- 
ous forms  of  psychic  degeneration  are  manifold.  They  include 
an  excessive  impressionability,  a  tendency  towards  the  develop- 
ment of  hallucinations  and  delusions  whenever  the  bodily  re- 
sistance is  at  all  lowered,  anomalous  affective  states,  excessive 
development  of  the  imagination,  a  tendency  to  lie,  and  not  in- 


1 86  PSYCHIATRY 

frequently  the  various  imperative  processes,  impulses,  phobias, 
and  so  on.  all  of  which  symptoms  are  generally  characterized 
by  a  certain  degree  of  periodicity,  becoming  more  marked  when 
the  individual  is  obliged  to  live  in  an  atmosphere  which  throws 
too  great  a  strain  upon  his  nervous  organism. 

What  is  greatly  needed  in  the  investigation  of  the  ques- 
tion of  the  hereditary  transmission  of  mental  diseases  are  care- 
fully planned  and  executed  studies  of  the  family  histories  of 
those  suffering  from  alienation,  carried  through  not  one  but 
over  several  generations.  As  the  question  of  environment  is 
such  a  difficult  one  to  eliminate,  it  is  better  that  for  the  present 
only  those  patients  be  selected  who  have  come  from  communi- 
ties in  which  there  has  been  comparatively  little  change  in  the 
habits  of  life  or  general  social  conditions  in  which  they  have 
been  born  and  brought  up. 

The  family  histories  on  the  following  page,  tabulated  by 
Dunton,  while  giving  an  important  clue  as  to  the  previous 
environment  in  which  the  patients  were  born  and  bred,  do  not 
offer  sufficient  data  upon  which  to  base  any  theory  in  regard 
to  the  direct  transmission  of  alienation. 

Environment. — In  this  connection  a  great  variety  of 
different  factors  directly  or  indirectly  provocative  of  alienation 
may  be  referred  to.  It  is  a  matter  of  common  observation  that 
mental  disorders  show  marked  variations  in  type  among  indi- 
viduals of  different  nationalities.  An  excellent  example  can 
be  obtained  from  a  study  of  the  various  forms  of  alcoholism. 
Thus,  in  southern  Italy  acute  alcoholism  is  practically  un- 
known, and  it  is  only  as  one  travels  northward  and  the  climatic 
conditions  change  that  there  is  a  notable  increase  in  the  num- 
ber of  the  acute  psychoses  resulting  from  this  form  of  intoxi- 
cation. Again,  general  paresis  is  found  much  less  frequently 
in  warm  climates  than  in  those  in  which  the  changes  of  tem- 
perature are  greater.  In  certain  countries,  such  as  Abyssinia, 
even  where  the  percentage  of  syphilis  among  the  natives  is 
very  high,  cases  of  general  paresis  are  almost  unknown.  More 
than  one  observer  has  called  attention  to  the  fact  that  there  are 


CAUSES    OF   INSANITY 


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1 88  PSYCHIATRY 

essential  differences  to  be  noted  in  regard  to  the  various  types 
of  mental  diseases  which  are  found  in  America  as  compared 
with  those  in  Europe.  Thus  White  9  has  recently  shown  that 
the  types  of  alienation  vary  in  different  parts  of  the  United 
States;  and  the  observations  made  by  members  of  the  staff 
at  the  Sheppard  and  Enoch  Pratt  Hospital  would  seem  to  indi- 
cate that  the  incidence  of  cases  which  resemble  Meynert's 
amentia  is  greater  than  that  noted  in  certain  clinics  abroad, 
particularly  at  Heidelberg,  where  this  symptom-complex  seems 
to  be  comparatively  infrequent.  Again,  the  statistics  of 
Vienna,  when  compared  with  those  of  Heidelberg,  show  a  more 
frequent  occurrence  of  this  form  of  alienation  in  the  Austrian 
capital.  The  several  mental  disorders  which  are  the  result  of 
drug  intoxications  other  than  alcoholism  naturally  vary  in 
different  localities.  Thus,  for  example,  it  is  not  surprising  to 
find  that  cocainism  is  more  prevalent  in  the  countries  in  which 
the  drug  is  indigenous  or  that  the  psychoses  associated  with  the 
eating  and  smoking  of  opium  and  the  indulgence  in  the  use  of 
hashish  are  more  common  in  the  East.  The  frequency  with 
which  purely  functional  disorders,  such  as  psychasthenia  and 
epilepsy,  are  met  with  varies  greatly  in  different  parts  of  the 
world,  while  certain  curious  symptoms,  such  as  Latah,  or  the 
phenomena  of  "  running  Amok,"  as  found  among  the  Malays, 
are  almost  entirely  confined  to  certain  localities. 

Not  only  are  different  environments  productive  of  certain 
more  or  less  specific  forms  of  alienation,  but  the  change  from 
one  to  another  may  be  followed  by  equally  unfortunate  results, 
causing  outbreaks  of  insanity  among  those  who  are  mentally 
or  physically  unable  to  properly  adjust  their  lives  to  the  new 
surroundings.  Instances  of  this  influence  are  often  noted  in 
connection  with  persons  who  have  left  their  homes  to  take 
up  their  residence  in  foreign  countries.  Mental  disturbances 
of  a  more  or  less  peculiar  character  are  noted  in  the  English 
people  who  spend  portions  of  their  lives  in  India,  as  well  as  in 


9  Geographical  Distribution  of  Insanity  in  the  United  States.    Journal 
of  Nervous  and  Mental  Diseases,  May,  1903. 


CAUSES  OF  INSANITY  189 

Americans  who  migrate  to  tropical  climates.  The  outbreaks 
of  insanity  among  our  soldiers  in  the  Philippine  Islands  present 
problems  that  deserve  careful  consideration. 

The  subject  of  environment  also  necessitates  the  discus- 
sion of  local  differences  as  well  as  the  more  immediate  sur- 
roundings which  an  individual  creates  for  himself.  The  types 
of  alienation  differ  even  among  individuals  who  live  in  the 
same  locality.  Thus  the  negroes  and  the  whites  living  in  the 
same  State  will  show  certain  differences  in  the  types  of  mental 
disorders  from  which  they  suffer.  Again,  members  of  the  Jew- 
ish race,  no  matter  where  they  live,  are  generally  thought  to 
be  particularly  susceptible  to  nervous  and  mental  diseases. 

Sudden  changes  in  environment  occurring  to  individuals 
or  whole  races  are  frequently  followed  by  an  outbreak  of  alien- 
ation. Statistics  show  a  great  increase  in  the  number  of  men- 
tal diseases  following  the  sudden  acquisition  of  wealth  either 
by  individuals  or  by  communities.  It  is  true  that  the  excep- 
tional man  may  be  able  to  withstand  sudden  changes  in  his 
environment,  but  for  the  mentally  unstable  individual  any 
marked  and  rapid  alteration  in  his  surroundings,  whether  it 
be  in  the  nature  of  an  elevation  or  lowering,  is  unquestionably 
associated  with  great  danger.  These  undoubted  facts  demand 
the  earnest  consideration  of  those  who  are  striving  for  the 
so-called  elevation  of  the  masses.  To  "  hasten  slowly"  may 
in  the  end  prove  to  be  the  kindest  method. 

Another  important  element  in  the  causation  of  alienation 
is  the  great  tendency  shown  to  leave  the  country  and  congre- 
gate in  cities.  But  while  the  dangers  of  too  great  centralization 
can  hardly  be  overrated,  it  should  not  be  forgotten  that 
many  persons  who  live  in  the  country  create  for  themselves  an 
artificial  environment  and  live  in  a  manner  which  is  quite  as 
detrimental  to  their  mental  welfare  as  is  the  life  of  the  indi- 
vidual in  a  crowded  city.  Monotony  as  well  as  over-excitement 
is  provocative  of  mental  disorders.  There  can  be  little  doubt, 
however,  that  every  social  movement  which  tends  to  check  the 
enormous  increase  in  the  population  of  the  cities  and  to  send 
many  back  to  a  rural  life  deserves  to  be  encouraged. 


190 


PSYCHIATRY 


The  various  conditions  associated  with  the  individual's 
daily  life  and  work  are  also  of  importance  in  this  connection. 
Here  we  find  a  great  variety  of  causes  operative  which  pre- 
dispose towards  alienation.  As  has  been  mentioned  elsewhere, 
it  has  long  been  a  matter  of  observation  that  workers  in  lead 
and  various  other  toxic  substances  show  a  marked  tendency 
towards  the  development  of  alienation.10  In  fact,  nearly  every 
form  of  occupation  has  its  own  especial  dangers  for  the  indi- 
vidual who  is  weakly  and  who  has  inherited  or  developed  a 
tendency  to  succumb  to  nervous  or  mental  strain. 

As  far  as  the  professions  are  concerned,  it  hasr  long  been 
generally  recognized  that  those  which  tend  to  develop  the  emo- 
tional life  at  the  expense  of  the  other  faculties  have  special 
dangers  of  their  own.  Thus  artists  and  musicians,  who  have 
allowed  their  lives  to  become  too  one-sided,  are  often  found 
to  possess  an  unstable  mental  equilibrium. 

The  effects  of  environment  in  the  production  of  fatigue 
are  considered  elsewhere.  Provided  the  individual  is  placed  in 
hygienic  surroundings  and  receives  proper  nutrition,  it  may 
be  said  that  hard  work — if  anxiety  and  worry  are  eliminated 
— never  results  in  alienation.  On  the  other  hand,  individuals 
who  have  no  regular  work  and  no  incentive  in  life  readily  be- 
come a  prey  to  nervous  and  mental  disorders ;  nor  need  we  go 
far  to  seek  for  an  explanation  for  the  great  prevalence  of  men- 
tal disturbances  among  the  tramp  class,  as  well  as  among  the 
well-to-do  members  of  society  who  are  without  definite  occu- 
pation. 

Imitation  and  Suggestion.11 — In  the  history  of  the 
human  race  the  phenomena  included  under  these  two  terms 
have  played  a  most  important  part,  but  here  only  their  relation 
to  mental  disorders  will  be  discussed.  The  so-called  epidemic 
psychoses  that  were  of  so  frequent  occurrence  during  the  Mid- 

10  Meillere,  G. :  Le  Saturnisme.  Etude  historique,  physiologique, 
clinique  et  prophylatique.     Paris,  1903. 

11 V.  Bechterew :  Suggestion  u.  ihre  sociale  Bedeutung.  Deutsch  von 
Weinberg.     Leipzig,  1899. 


CAUSES    OF   INSANITY  191 

die  Ages  have  deservedly  attracted  the  attention  of  physicians 
as  well  as  the  laity.  These  manifestations  develop  in  connec- 
tion with  the  social,  religious,  and  political  life  of  peoples,  and 
at  a  time  when  the  true  nature  of  mental  disorders  was  not 
understood,  it  was  thought  that  a  direct  transmission  of  thought 
and  energy  through  the  agency  of  unseen  powers  took  place. 
But  even  as  early  as  the  fifteenth  or  sixteenth  centuries  there 
were  a  few  intelligent  physicians  who  recognized  that  the  pro- 
nounced psychoses,  such  as  melancholia  and  mania,  never  ap- 
peared in  epidemic  form,  and  to-day  it  is  generally  agreed  that 
alienation  is  not  capable  of  being  spread  by  mere  imitation  or 
suggestion. 

The  folie  a  deux  is  occasionally  seen,  two  or  three,  but 
never  more,  members  of  the  same  family  being  afflicted.  These 
rare  cases  of  so-called  psychic  infection  are  only  observed 
where  individuals  are  in  constant  communication  with  insane 
patients.  Thus,  two  friends  occupying  the  same  room,  two 
members  of  the  same  family,  more  especially  two  brothers  or 
two  sisters  or  a  brother  and  a  sister,  sometimes  become  insane 
almost  at  the  same  time.  A  similar  misfortune  has  occasion- 
ally been  known  to  afflict  both  husband  and  wife.  Such  forms 
of  mental  disturbance  never  occur  except  in  hereditarily  pre- 
disposed individuals,  and  the  alienation  which  results  is  usually 
one  of  the  more  chronic  types.  Probably  the  majority  of  cases 
reported  as  instances  of  psychic  infection  are  erroneously  clas- 
sified, since  in  reality  no  transmission  of  the  disorder  has 
occurred,  but  it  has  merely  happened  that  the  same  etiological 
factor  has  been  active  in  both  cases.  Certainly,  the  cases  of 
so-called  conjugal  dementia  paralytica  are  not  to  be  classified 
in  this  category. 

As  the  etiology  of  mental  disorders  has  become  a  subject 
for  more  exact  study  and  investigation,  it  has  been  found  neces- 
sary to  define  as  nearly  as  possible  in  each  individual  case  a 
series  of  phenomena  that  are  designated  as  suggestive.  As  the 
clinical  facts  have  gradually  been  gathered  together,  it  has  been 
discovered  that  not  one,  but  a  great  variety  of  conditions  may 
give  rise  to  the  manifestations  belonging  to  what  is  termed 


192 


PSYCHIATRY 


suggestion.  To  Charcot  and  his  scholars  we  owe  a  great  debt 
of  gratitude  for  first  taking  the  investigation  of  these  phe- 
nomena out  of  the  hands  of  those  who  were  actuated  by  super- 
stition and  fear  or  guided  by  a  merely  speculative  philosophy. 
As  a  result  of  the  influence  of  the  French  school,  psychologists 
and  alienists  began  to  give  this  subject  the  attention  it  de- 
served. Unquestionably,  many  of  the  great  movements  in 
religion,  politics,  and  sociology  have  been  the  immediate  result 
of  the  suggestibility  among  races,  nations,  or  sects.  The  per- 
secutions in  the  Middle  Ages  of  those  who  were  supposed  to 
be  possessed,  the  burning  of  witches,  and  in  more  modern  times 
Mahdism,  Dowieism,  Christian  Science,  the  remarkable  ser- 
vices and  revival  meetings  of  certain  religious  sects,  anarchism, 
and  a  host  of  other  social  and  political  fads  can  be  traced  to 
this  origin.  Friedmann  believes  that  the  fundamental  psycho- 
logical defect  is  not  an  affective  one,  but  that  the  character  of 
the  representation  or  the  idea  in  consciousness  is  the  essential 
dynamic  force.  Hellpacht 12  affirms  that  suggestibility  may 
be  regarded  as  an  evidence  of  quantitative  disproportion  be- 
tween the  emotional  state  and  its  expression,  the  latter  being 
more  or  less  impaired.  This  disparity  is  eminently  character- 
istic of  the  hysterical  individual. 

In  attempting  to  determine  whether  a  given  case  is  one 
of  so-called  induced  insanity  we  have  to  distinguish  between 
a  variety  of  different  conditions.  In  the  first  place,  induced 
insanity,  in  the  sense  in  which  the  term  is  often  used,  may  be 
said  to  be  present  when  alienation  develops  in  an  individual 
who  has  been  for  a  more  or  less  prolonged  period  of  time  in 
close  contact  with  a  patient  suffering  from  insanity.  The  alien- 
ation is  of  the  same  type  in  the  second  as  in  the  first  patient, 
and  continues  after  the  two  individuals  have  been  separated. 
Such  examples,  however,  are  but  rarely  met  with. 

Much  more  frequent  in  occurrence  is  the  second  form,  in 


12  Hellpacht,  Willy :  Analytische  Untersuchungen  zur  Psychologie  der 
Hysteric  Centralbl.  f.  Nervenheilk.  u.  Psych  ,  1903,  Dezember,  N.  F.,  Bd. 
xiv,  S.  737. 


CAUSES    OF   INSANITY  193 

which  an  individual  who  has  exhibited  a  marked  predisposition 
towards  nervous  or  mental  disease  shows  symptoms  of  insanity 
immediately  after  having  been  brought  into  contact  with  a 
well-defined  case  of  insanity.  This  type  is  well  represented  in 
many  forms  of  hysteria  or  the  paranoioid  states,  as  well  as  in 
the  so-called  conjugal  insanity  where  both  man  and  wife  suffer 
from  mental  depression. 

In  a  third  form  individuals  who  have  already  shown  signs 
of  insanity  imitate  the  symptoms  of  the  patients  with  whom 
they  are  brought  into  contact.  This  is  particularly  noticeable 
in  cases  of  hysteria  and  dementia  prsecox. 

Finally,  normal  individuals  who  have  been  continuously 
associated  with  persons  suffering  from  mental  disease  occa- 
sionally acquire  certain  idiosyncrasies  of  character  and  tem- 
perament. Instances  of  this  are  not  uncommon  among  asylum 
attendants  and  care-takers  of  insane  patients. 

Sex.13 — Difference  in  sex  is  generally  supposed  to  play 
an  important  part  in  the  pathogenesis  of  alienation.  In  the 
consideration  of  this  question  it  is  essential  to  distinguish  be- 
tween what  may  be  called  the  innate  differences  between  the 
male  and  female  and  those  that  are  the  result  of  environment 
and  education.  Although  a  great  deal  has  been  written  regard- 
ing the  so-called  primary  distinctions,  very  little  is  definitely 
known  about  them,  and  the  problem  is  one  which  needs  to  be 
much  more  carefully  investigated.  Until  the  years  of  puberty, 
however,  it  may  be  said  that  no  very  marked  differences  as 
regards  innate  mental  qualities  exist  between  boys  and  girls. 
The  fact  that  from  time  immemorial  it  has  been  the  cus- 
tom to  treat  the  two  sexes  differently  makes  it  still  more 
difficult  to  decide  what  has  been  inborn  in  either  sex  and  what 
has  resulted  from  environment;  nor  can  we  expect  that  the 
work  so  far  done  by  the  psychologists  will  give  us  much  aid 
towards  solving  the  problem.  Nevertheless,  some  little  might 
be  learned  from  a  long  series  of  observations,  conducted  by 


13  Ellis,  H. :   Man  and  Woman.    London,  1894.    Mobius,  P.  J. :    Gesch- 
lecht  u.  Krankheit — Geschlecht  u.  Entartung.    Halle,  1903. 

13 


194 


PSYCHIATRY 


carefully  trained  observers,  upon  the  development  of  normal 
children,  under  such  conditions  that  the  factor  of  environment 
could  be  reduced  to  the  minimum.     After  puberty,  however, 
in  normal  types  easily  recognizable  differences  in  the  mental 
powers  of  the  two  sexes  develop,  but  how  far  these  changes 
are  the  result  of  innate  qualities  and  how  far  the  result  of 
environment  and  training  it  is  impossible  to  say.     The  impor- 
tant part  that  puberty  plays  in  mental  development  has  been 
recognized  by  the  laity  as  well  as  by  scientific  investigators.14 
Although  many  important  facts  have  already  been  brought  to 
light  regarding  the  physical  and  mental  changes  which  occur 
in  males  and  females  at  this  period,  there  are  still  many  points 
which  need   further  elucidation.      Differences   in  climate,    in 
race,  and  in  social  conditions,  and  a  great  number  of  other 
important  factors  must  be  taken  into  account  before  it  is  pos- 
sible to  make  any  very  broad  generalizations.    The  premature 
onset  of  puberty,  which  frequently  happens  in  the  Southern 
races,  is  certainly  of  significance  in  the  pathogenesis  of  various 
nervous  and  mental  disturbances.    On  the  other  hand,  the  delay 
of  puberty  points  to  retarded  development,  and  inasmuch  as 
the  growth  of  the  individual  depends  upon  so  many  various 
factors,  it  becomes  apparent  that  the  discussion  of  this  whole 
question  involves  the  consideration  of  a  series  of  complex  prob- 
lems, for  the  solution  of  which  the  mere  appearance  or  absence 
of  certain   sexual   characteristics  offers  nothing  final.      The 
physical  changes  that  are  associated  with  puberty  are  largely 
influenced  by  the  general  nutrition  of  the  individual  boy  or 
girl,  and  any  deficiencies  in  metabolism  are  apt  to  be  followed 
by  retarded  or  faulty  development.     Nothing  is  more  common 
in  anaemic  girls  than  to  find  that  the  period  of  puberty  has  been 
delayed.     Unfortunately,   the  laity  and   even  physicians  too 
often  attribute  the  various  forms  of  nervous  breakdown  which 
occur  at  this  time  solely  to  the  absence  of  the  menses,  whereas 

14  Marro,  A. :  La  puberte  chez  l'homme  et  chez  la  femme,  etudiee  dans 
ses  rapports  avec  l'anthropologie,  la  psychiatrie,  la  pedagogie  et  la  sociol- 
ogie.  Traduit  sur  la  deuxieme  edition  italienne  par  J.  P.  Medici.  Biblio- 
theque  des  sciences  anthropologiques,  i.     Paris,  1902. 


CAUSES    OF   INSANITY  195 

in  reality  the  amenorrhoea  is  merely  one  of  the  symptoms  of 
a  general  constitutional  disturbance. 

At  this  period,  when  the  diverging  sexual  characteristics 
are  becoming  fully  developed,  the  influence  of  heredity,  alco- 
holism in  the  parents,  of  poverty,  malnutrition,  and  affective 
disturbances  become  of  even  greater  importance  than  they  have 
been  before,  especially  as  regards  the  development  of  the  men- 
tal functions.  We  not  infrequently  meet  with  emotional  dis- 
turbances of  varying  degree  which  may  ultimately  give  rise  to 
nervous  and  mental  symptoms  of  considerable  significance. 
The  exact  causes  of  these  anomalies  are  not  definitely  known, 
but  alienists  have  long  been  accustomed  to  speak  of  the  puberty 
psychoses  or  of  the  insanity  of  adolescence  as  if  there  were 
specific  forms  of  alienation  occurring  at  this  period. 

Between  the  years  of  puberty  and  the  time  when  the 
woman  is  no  longer  capable  of  bearing  children  she  is  much 
more  predisposed  to  mental  disturbances  than  the  average  man. 
This  condition  of  affairs  naturally  depends  upon  the  nervous. 
and  mental  disturbances  associated  with  pregnancy  and  par- 
turition, or,  on  the  other  hand,  with  sterility  and  its  underlying 
causes.  A  similar  predisposition  also  becomes  manifest  at  the 
approach  of  the  menopause,  although  it  must  be  insisted  that 
the  real  tendencies  towards  mental  breakdown  that  exist  at  this 
time  are  greatly  intensified  by  the  promulgation  of  popular  be- 
liefs and  superstitions  which  have  little  foundation  in  fact.  It 
is  a  matter  of  clinical  experience  that,  as  a  rule,  a  woman  is 
more  predisposed  towards  mental  depression  than  a  man. 
Nor  is  this  unnatural  when  we  take  into  consideration  the  fact 
that  she  has  less  independence,  and  if  obliged  to  earn  her  living 
has  greater  difficulties  to  overcome.  This  explanation,  how- 
ever, offers  only  a  partial  solution  of  the  phenomena. 

In  cases  of  manic-depressive  insanity,  as  a  rule,  it  may 
be  said  that  the  periods  of  depression  are  longer  and  more 
intense  in  the  female  than  in  the  male,  whereas  the  symptoms 
of  excitement  and  exhilaration  are  less  frequently  met  with. 
In  other  psychoses  we  also  encounter  certain  differences  in 
the  type  of  the  disease  which  seem  to  bear  some  relation  to 


196  PSYCHIATRY 

sexual  differences.  For  example,  in  dementia  paralytica  the 
classical  type  of  the  disease  is  almost  never  met  with  in  women, 
in  whom  it  appears  almost  always  in  the  depressed  form.  As 
a  matter  of  fact,  this  disorder  is  comparatively  infrequent  in 
women,  especially  those  of  the  higher  classes,  the  majority  of 
female  paretics  coming  altogether  from  the  lowest  elements 
of  society. 

Age. — The  great  majority  of  cases  of  alienation  come  on 
during  the  prime  of  life  at  a  period  when  the  individual  is 
exposed  to  the  greatest  stress  and  strain.  Nevertheless,  besides 
the  defect  psychoses,  various  acute,  subacute,  and  chronic  men- 
tal disorders  are  sometimes  met  with  even  in  very  young  chil- 
dren. Thus,  hysteria  is  not  very  uncommon  in  the  very  early 
years  of  childhood,  and  competent  observers  have  reported  de- 
lirious states  occurring  during  infancy.  Every  teacher  in  the 
public  schools  meets  with  children,  even  among  the  very  young, 
who  show  marked  anomalies  in  conduct,  and  who  are  generally 
regarded  as  bad  characters  or  as  more  or  less  incorrigible  de- 
linquents and  a  menace  to  their  fellow-scholars.  These  chil- 
dren are  sometimes  referred  to  by  medical  writers  as  degener- 
ates or  mentally  ill-balanced. 

In  addition  to  the  hysterical  states  the  psychic  epilepsies 
are  not  at  all  uncommon  in  young  children.  Thus,  Pick  15  has 
recently  called  attention  to  an  important  psychoneurosis  occur- 
ring in  the  earlier  years  of  life  which  has  certain  characteristics 
suggestive  of  epilepsy,  and  says  that  the  children  afflicted  in 
this  way  show  symptoms  of  so-called  wandering  mania  (poro- 
mania  or  dromomania)  associated  with  signs  of  episodic  emo- 
tional irritability,  mental  dulness,  wilfulness,  and  impulsivity. 
In  addition  to  states  characterized  by  the  more  pronounced 
symptoms  of  alienation  we  meet  with  a  variety  of  manifesta- 
tions which  should  at  once  lead  the  physician  to  suspect  the 
existence  of  anomalies  in  the  functioning  of  the  central  ner- 
vous system.     We  are  often  told  that  an  individual,  who  later 


15  Pick,  A. :    Ueber  einige  bedeutsame  Psycho-Neurosen  des  Kindes- 
alters.    Halle  a/S.,  1904. 


CAUSES    OF    INSANITY  197 

has  shown  symptoms  of  alienation,  was  unusually  bright  dur- 
ing the  earlier  years  of  life,  whereas,  as  a  matter  of  fact,  ob- 
servations which  have  been  made  upon  this  point  in  nowise 
confirm  the  correctness  of  this  popular  opinion.  Healthy  boys 
and  girls  are  far  more  apt  to  show  exceptional  mental  qualities 
than  those  who  later  in  their  careers  break  down  mentally 
(Thorndike). 

From  the  onset  of  puberty  until  the  first  symptoms  of  old 
age  begin  to  make  their  appearance  the  number  and  variety  of 
mental  diseases  increase  greatly,  largely  because  during  the 
prime  of  life  the  individual  is  subjected  to  the  severest  tax 
upon  his  mental  as  well  as  upon  his  physical  powers.  The 
conditions  which  in  women  during  this  period  are  particularly 
apt  to  give  rise  to  mental  breakdowns  are  referred  to  in  an- 
other section.  In  males  we  find  a  great  difference  in  the  inci- 
dence of  the  several  types  of  alienation.  Thus,  men  from 
about  35  to  50  are  much  more  subject  to  general  paresis  than 
at  any  other  period  of  life.  As  old  age  comes  on  the  types  of 
mental  disorders  are  different  from  those  in  earlier  life,  since 
they  are  associated  with  certain  degenerative  changes  in  the 
central  nervous  system  that  are  apt  to  lead  to  the  production 
of  a  more  or  less  characteristic  group  of  clinical  symptoms 
belonging  more  particularly  to  forms  of  the  so-called  senile 
alienation.  The  relative  frequency  of  incidence  at  the  various 
ages  will  be  considered  in  fuller  detail  in  the  discussion  of  the 
several  groups  of  mental  diseases. 

Education. — If  a  training  in  pedagogics  gave  teachers 
a  clearer  and  more  practical  insight  into  actual  life  as  well  as 
some  appreciation  of  the  beginning  pathological  tendencies  of 
humanity,  many  failures  would  be  avoided  and  many  difficul- 
ties would  be  overcome  (Von  Krafft-Ebing).  The  instances 
in  which  a  profession  ill  adapted  to  the  individual  capabilities 
is  chosen  would  be  less  frequent,  and  thus  the  mental  life  of 
numbers  would  be  preserved  intact.  There  is  probably  no 
greater  fallacy  than  to  regard  the  education  given  in  our  public 
schools  as  a  cure-all  for  the  many  deficiencies  of  our  social  and 
political  system.     Unquestionably,  much  good  may  be  accom- 


198  PSYCHIATRY 

plished  in  the  attempt  to  educate  the  masses,  provided  some 
selection  is  made  in  the  choice  of  those  who  are  to  be  given  the 
advantages  of  a  school  training.  That  the  enormous  increase 
of  nervous  and  mental  diseases,  one  of  the  most  serious  men- 
aces to  the  public  welfare,  is  the  immediate  result  of  trying  to 
educate  numbers  of  individuals  whose  central  nervous  systems 
are  functionally  unable  to  withstand  the  strain  imposed  upon 
them,  is  obvious  to  all  those  who  are  competent  to  judge  of 
such  matters.  If  the  aid  of  intelligent  physicians  were  sought 
in  determining  the  question  as  to  what  children  were  fitted  to 
receive  a  public  school  education,  unquestionably  many  cases 
of  insanity  which  develop  later  in  life  would  never  occur.  It 
is  a  curious  comment  upon  popular  government  that  so  little 
effort  is  being  made  along  these  lines,  and  that,  while  the  pub- 
lic has  the  right  to  prevent  the  spread  of  measles  or  scarlet 
fever,  it  assumes  no  authority  in  matters  relating  to  the  pre- 
vention of  alienation.  Only  in  certain  Continental  cities  is 
any  effort  being  made  to  limit  the  advantages  and  risks  of  edu- 
cation in  the  public  schools  to  those  who  have  sound  bodies 
and  sound  minds,  and  nowhere  have  these  questions  received 
the  attention  they  deserve. 

The  first  duty  of  the  educator  should  be  to  determine  the 
latent  capacity  of  the  individual  and  then  adapt  the  training 
as  far  as  possible  to  meet  the  needs  of  the  developing  nervous 
system.  To  render  it  possible  for  an  individual  who  is  physi- 
cally and  mentally  unfitted  for  the  stress  associated  with  the 
effort  to  undertake  the  acquirement  of  what  is  termed  a  liberal 
education  should  be  regarded  as  an  offence  against  the  public 
health  and  morality  no  less  culpable  than  if  one  were  to  deliber- 
ately place  him  in  an  environment  where  he  is  exposed  to  an 
infectious  disease.  What  particular  form  of  education  is  best 
adapted  to  the  average  child?  How  far  should  the  negro  be 
carried  in  his  schooling?  Of  what  degree  of  mental  activity 
is  woman  capable  without  impairing  her  physical  vigor?  These 
are  not  questions  that  can  be  solved  by  mere  amateurs,  but 
involve  problems  calling  for  the  earnest  consideration  of  those 
who  are  at  least  familiar  with  the  methods  of  investigating  the 


CAUSES    OF   INSANITY  199 

difficulties  connected  with  the  functional  activity  of  the  cen- 
tral nervous  system. 

It  is  much  to  be  regretted  that  some  of  the  ill-directed  zeal 
which  seeks  to  impose  needless  restrictions  upon  proper  experi- 
mentation upon  the  lower  animals  cannot  be  directed  into  chan- 
nels where  it  will  serve  to  prevent  educational  faddists  from 
inflicting  irreparable  injury  upon  the  brains  of  those  who  are 
intrusted  to  their  care.  Quite  as  much  technical  skill  and  ex- 
perience is  required  to  form  a  correct  estimate  of  the  functional 
capacity  of  the  brain  as  to  determine  whether  the  heart  or  lungs 
are  normal ;  and  the  ignorance  upon  these  topics  displayed  by 
those  who  are  supposed  to  be  authorities  upon  questions  of 
education  is  greatly  to  be  deplored. 

Fatigue.16 — Recent  investigations  have  shown  that  the 
manifestations  grouped  under  this  term  are  varied  and  ex- 
ceedingly complex.  The  mental  and  physical  anomalies  com- 
monly described  as  evidences  of  fatigue  are  only  in  part  the 
result  of  long-continued  activity,  since  other  factors  are  almost 
always  present.  These  symptoms  vary  considerably,  not  only 
in  different  persons,  but  in  the  same  individual  under  different 
circumstances.  The  mental  symptoms  of  fatigue  may  be  de- 
scribed as  a  weakening  of  the  attention,  a  lowering  in  the  proc- 
esses of  associative  memory,  and  disturbances  in  organic  sen- 
sibility of  an  anaesthetic  or  more  generally  of  a  paresthetic 
nature.  The  work  of  Weygandt 17  as  well  as  that  of  Aschaf- 
fenburg,  of  Patrick  and  Gilbert,18  of  Mosso,19  of  Binnet  and 
Henri,20  Joteyko,21  Mainzer,22  as  well  as  of  other  investigators, 


16  Fatigue,  Mental  and  Physical,  with  Bibliography.  Dictionary  of 
Philosophy  and  Psychology.  Baldwin.  New  York  and  London,  1901,  vol. 
i.  P-  374- 

17  Psychologische  Arbeiten,  4,  45. 

18  Psychological  Review,  September,  1896. 
"La  fattica,  1891. 

"La  fatigue  intellectuelle,  1898. 

21  Joteyko,  I. :  Fatigue.    Dictionn.  Physiol.,  Charles  Richet,  Paris,  1903. 

22  Stoffwechselstudien  iiber  den  Einfluss  geistiger  Thatigkeit  und  pro- 
trahierten  Wachens.  Monatsschr.  f.  Psych,  u.  Neurol.,  1903,  Bd.  xiv,  H. 
6,  S.  442. 


200  PSYCHIATRY 

has  already  thrown  considerable  light  upon  the  genesis  of  this 
somewhat  complex  group  of  phenomena.  In  the  light  of  these 
investigations  an  attempt  has  been  made  to  study  the  devel- 
opment of  the  symptoms  in  various  psychoses  in  which  fatigue 
is  supposed  to  be  an  important  etiological  factor.  So  far,  how- 
ever, the  results  obtained  have  not  been  entirely  satisfactory, 
as  it  has  been  impossible  to  analyze  all  the  various  factors 
which  must  be  taken  into  account  before  any  trustworthy  de- 
ductions are  drawn,  and  consequently  any  attempt  to  differen- 
tiate the  fatigue  psychoses  from  other  forms  of  alienation  can 
not  at  present  be  satisf actory.  The  work  of  Hodge  and  others 
showed  that  after  excessive  fatigue  it  was  possible  to  demon- 
strate in  the  ganglion  cells  of  the  central  nervous  system 
changes  which  were  supposed  to  be  more  or  less  specific.  More 
recent  investigations,  however,  seem  to  render  it  highly  proba- 
ble that  the  effect  of  fatigue  upon  the  nerve-elements  is,  largely 
at  least,  indirect,  and  comes  about  through  the  production  of 
an  autointoxication.  Not  a  few  investigators  have  made  an 
attempt  to  determine  exactly  the  character  of  the  toxins  formed 
during  the  fatigue  process,  but  as  yet  the  results  are  meagre 
and  unsatisfactory.  Rauke,  as  long  ago  as  1865,  suggested 
that  the  change  in  the  character  of  the  muscular  contractions 
might  be  due  to  the  heaping  up  in  the  system  of  toxic  products, 
a  view  which  more  recently  has  again  been  advocated  by 
Mosso,  Schiff,  and  others.  Weichardt 23  conducted  a  number 
of  experiments  upon  mice  to  determine,  if  possible,  the  exist- 
ence of  a  blood-serum  containing  toxic  products  the  result  of 
fatigue.  He  found  that  no  definite  results  follow  the  intra- 
peritoneal injections  of  the  blood-serum  of  fatigued  mice  as 
compared  with  the  injection  of  that  taken  from  normal  ani- 
mals. In  both  series  of  cases  fatal  results  followed  the  injec- 
tion. Practically  the  same  results  followed  intravenous  injec- 
tions except  that  after  the  normal  as  well  as  the  serum  from  the 
fatigued  animals  fat  embolism  resulted.     These  results  were 


23  Ueber     Ermiidungstoxine    und    deren    Antitoxine.       Munch,     med. 
Wchnschr.,  1904,  Januar,  Nr.  1,  51.  Jahrg.,  Erste  Mitteilung. 


CAUSES    OF    INSANITY  201 

still  further  confirmed  by  observations  upon  rabbits  and  guinea- 
pigs.  After  considerable  difficulty  somewhat  more  positive 
results  were  obtained  by  experimenting  with  the  muscle  of 
animals  which  had  been  previously  subjected  to  fatigue.  Here 
it  was  found  that  if  the  muscle-plasma  of  very  much  fatigued 
animals  was  injected  subcutaneously,  death  resulted  after  a 
period  varying  from  twenty  to  forty  hours.  It  was  further 
noted  that  no  fatal  results  followed  when  the  plasma,  before 
being  injected,  was  placed  in  a  thermostat  for  two  hours  at 
a  temperature  of  560  C,  whereas  the  plasma  which  was  not 
warmed  but  was  allowed  to  stand  for  forty-eight  hours  in- 
creased greatly  in  its  toxicity.  Nevertheless,  after  being  pre- 
served for  eight  days  in  the  ice-chest  with  the  addition  of  toluol 
it  had  practically  lost  its  toxicity.  Weichardt  was  further  able 
to  demonstrate  that  by  intraperitoneal  injections  of  the  toxic 
muscle-plasma  obtained  from  fatigued  andimals  an  antitoxic 
serum  could  be  derived  which  apparently  neutralized  the  toxins 
produced  by  fatigue. 

Trauma. — The  importance  of  trauma  as  an  etiological 
factor  in  the  production  of  alienation  has  long  been  recognized, 
although  physicians  have  differed  essentially  in  regard  to  the 
relation  of  the  injury  to  any  special  type  of  psychosis.  Grad- 
ually it  has  been  generally  concluded  that  there  is  no  specific 
psychosis  resulting  from  trauma,  although  a  few  clinicians  still 
describe  a  symptom-complex  which  they  call  a  post-traumatic 
dementia.  About  all  that  can  be  said  upon  this  point  is  that 
trauma  is  a  predisposing  factor  to  alienation,  and  that  as  a 
result  of  a  blow  upon  the  skull  the  brain  may  become  a  locus 
minoris  resistentice.  The  difficulty  of  determining  the  exact 
importance  of  trauma  is  greatly  increased  in  the  case  of  an 
individual  who  previously  has  shown  a  marked  predisposition 
towards  mental  disorder  or  where  a  history  of  lues  or  alcohol 
is  obtained. 

As  has  often  been  pointed  out,  the  effect  of  trauma  upon 
the  cerebral  functions  is  essentially  different  in  infants  or  chil- 
dren from  that  in  adult  life.  During  intra-uterine  life  or  at 
the  time  of  labor  the  skull  may  be  subjected  to  mechanical 


202  PSYCHIATRY 

injuries,  as  a  consequence  of  which  hemorrhages  from  the 
cerebral  vessels  may  result  with  destruction  of  the  cortical 
tissue  and  the  production  of  porencephalic  areas,  atrophy  of 
the  hemispheres,  or  irregular  development  of  the  cerebral  gyri. 
Fletcher  Beach,  in  examining  810  idiots,  found  that  in  35  cases 
the  injury  to  the  central  nervous  system  could  be  directly  re- 
ferred to  the  use  of  instruments  at  birth,  but  also  noted  that  in 
216  cases  impairment  of  the  psychical  functions  had  followed 
difficult  labor  without  instrumental  delivery.  Kuntzel  in  500 
cases  of  idiocy  estimated  that  in  8.9  per  cent,  forceps  had  been 
used;  whereas  in  4.5  per  cent,  a  difficult  but  non-instrumental 
delivery  was  a  factor  of  importance. 

Wulff  24  called  attention  to  the  impairment  of  the  intellec- 
tual faculties  following  trauma  occurring  either  during  intra- 
uterine life  or  at  the  time  of  birth,  and  has  traced  an  imme- 
diate connection,  in  1436  idiotic  children,  between  the  injury 
inflicted  and  the  following  conditions :  microcephalus,  adhe- 
sions between  the  dura  and  skull,  between  the  dura  and  pia, 
between  the  pia  and  brain,  pachymeningitis  chronica,  lepto- 
meningitis, hydrocephalus  externus,  hydrocephalus  internus, 
atrophy,  cerebral  sclerosis,  and  porencephalus. 

Sperking  and  Kronthal  25  were  among  the  first  to  describe 
definite  histological  changes  following  trauma,  consisting  in 
marked  sclerosis  with  local  hyaline  and  fatty  degeneration  in 
the  entire  arterial  system,  particularly  in  the  spinal  cord  and 
brain.  In  1897  Koeppen26  referred  to  the  microscopical 
changes  in  the  central  nervous  system  following  severe  trauma 
and  described  a  clinical  symptom-complex  characterized  by 
memory  defects,  irritability,  and  seizures  similar  to  those  of 
dementia  paralytica.  This  observer  believed  that  these  trau- 
matic psychoses  could  be  differentiated  from  dementia  para- 
lytica by  the  lesser  degree  of  impairment  of  the  intelligence  and 
interference  with  the  functions  of  speech  and  a  retained  pupil- 

24  Allg.  Ztschr.  f.  Psych.,  Bd.  xlix,  1893. 
25Neurolog.  Centralbl.,  1888. 

28  Koeppen  :   Ueber  Gehirnveranderungen  nach  Trauma.    Ref.  im  Neu- 
rolog.  Centralbl.,  1897. 


CAUSES    OF   INSANITY 


203 


lary  reflex.  Bruns  affirmed  that  the  presence  of  a  pupillary 
light  reflex  was  pathognomonic  of  the  traumatic  cases.  Studies 
of  experimental  lesions  produced  by  trauma  in  animals  showed 
that  marked  changes  were  present  in  the  nerve-cells.  Muralt 
has  described  catatonic  changes  following  trauma.  Viedenz  27 
has  carefully  reviewed  the  whole  subject,  and  comes  to  the 
following  conclusions : 

Injuries  to  the  skull  in  children  are  often  followed  by  de- 
mentia complicated  with  convulsive  seizures.  In  some  cases  in 
which  the  intelligence  is  well  preserved  there  may  be  a  degener- 
ation of  the  moral  sense.  Injuries  directly  affecting  the  central 
nervous  system  may  produce  psychoses  in  adults  who  have 
never  shown  any  predisposition  to  mental  disease;  but  the 
more  marked  the  predisposing  factor,  the  greater  the  tendency 
towards  the  development  of  alienation.  The  mental  dis- 
turbances may  develop  immediately  after  the  injury  or  after 
the  lapse  of  an  intervening  period,  during  which  prodromal 
symptoms  can  usually  be  detected.  A  specific  post-traumatic 
insanity  does  not  exist,  although  some  of  the  psychoses  follow- 
ing trauma  have  certain  features  in  common — changes  in 
character,  irritability,  memory  defects,  and  intolerance  for  alco- 
hol. Various  types  of  alienation  may  be  referred  to  this  as  the 
inciting  cause.  There  is  a  remarkable  similarity  between  the 
clinical  pictures  of  some  of  the  psychic  disturbances  following 
injuries  to  the  skull  and  certain  forms  which  are  attributable  to 
alcohol.  The  pathological  changes  are  rarely  characterized  by 
gross  lesions.  The  changes  in  the  smaller  blood-vessels  are 
marked.  No  specific  alteration  in  the  ganglion  cells  has  been 
noted.  Rosenfeld  28  has  reported  48  cases  of  hypochondriasis 
secondary  to  trauma,  and  as  a  result  of  his  investigation  affirms 
that  the  character  and  severity  of  the  trauma  are  not  the  only 
factors  which  determine  the  clinical  features  of  a  post-trau- 
matic psychosis.  Psychical  abnormalities,  such  as  feeble- 
mindedness of  various  degrees  or  a  predisposition  to  hypo- 
chondriacal  states,    are    factors    of   great  importance   in   the 

27  Arch.  f.  Psych,  u.  Nervenkrankh.,  Bd.  xxxvi,  H.  3,  p.  863. 

28  Centralbl.  f.  Nervenheilk.  u.  Psych.,  Bd.  xxvi,  Nr.  156,  1903. 


204 


PSYCHIATRY 


etiology.  The  trauma  may  merely  intensify  a  previously  ex- 
isting mental  deterioration. 

Adolf  Meyer  29  has  suggested  the  following  provisional 
classification  of  the  cases  of  alienation  following  trauma: 

( i )  The  direct  post-traumatic  deliria  with  febrile  reac- 
tions, the  delirium  nervosum  of  Dupuytren,  which  is  not  essen- 
tially different  from  the  mental  aberration  following  operations 
or  injuries,  and  a  condition  characterized  by  coma  developing 
in  alcoholic  as  well  as  non-alcoholic  subjects.  And,  finally,  a 
more  protracted  delirious  state,  with  marked  tendency  to  con- 
fabulate, which  may  or  may  not  be  associated  with  alcoholism 
or  senility. 

(2)  The  post-traumatic  constitution,  characterized  by  the 
excessive  reaction  of  the  individual  to  the  toxic  effects  of 
alcohol,  influenza,  etc.,  a  certain  type  of  vasomotor  neurosis, 
the  explosive  diathesis,  hysterioid  or  epileptoid  episodes,  with 
or  without  convulsions,  and,  finally,  a  paranoioid  state. 

(3)  Traumatic  defect  conditions — aphasias,  mental  de- 
terioration with  epilepsy  and  a  terminal  deterioration  due  to 
progressive  alterations  of  the  primarily  injured  parts,  either 
with  or  without  arteriosclerosis. 

(4)  Psychoses  in  which  trauma  is  merely  a  contributory 
factor — dementia  paralytica,  manic-depressive  insanity,  cata- 
tonic deterioration. 

(5)  -^  §"rouP  °f  traumatic  psychoses  following  injuries 
not  directly  affecting  the  head. 

Operations. — Psychoses  not  infrequently  develop  in  in- 
dividuals who  have  been  subjected  to  surgical  operations. 
These  post-operative  alienations  present  a  great  variety  of 
clinical  forms,  none  of  which  can  be  regarded  as  in  any  sense 
specific.  An  interesting  study  of  these  cases  from  a  clinical 
stand-point  has  been  made  by  Picque  and  Briand.30  In  a  large 
percentage  of  instances,  especially  in  patients  who  have  been 
operated  upon  while  in  a  weak  physical  condition,  symptoms 

29  Anatomical    Facts    and    Clinical    Varieties    of    Traumatic    Insanity. 
Am.  Journ.  of  Insan.,  1904,  January,  vol.  lx,  No.  30. 
80  Archives  de  Neurologie,  Mars,  1903,  No.  87. 


CAUSES    OF    INSANITY  205 

of  neurasthenia  develop,  but  these  forms  must  be  carefully  dis- 
tinguished from  those  in  which  the  symptoms  of  alienation 
are  marked.  To  another  distinct  class  belong  the  deliria  which 
develop  soon  after  an  operation  and  result  from  septic  intoxi- 
cation. Sometimes,  however,  symptoms  of  alienation  appear 
in  patients  who  have  recovered  from  the  immediate  effects  of 
the  operation,  and  which  cannot  therefore  be  referred  directly 
to  a  toxaemia.  In  such  cases  the  transitory  delirium  has  to  be 
regarded  as  an  epiphenomenon,  the  operation,  however,  being 
a  factor  of  some  considerable  etiological  importance.  Many 
authorities  believe  that  a  post-operative  psychosis  never  de- 
velops in  an  individual  who  has  not  previously  shown  some 
predisposition  to  alienation.  As  a  general  rule,  it  may  be 
assumed  that  the  variability  in  the  mentality  of  an  individual 
and  his  predisposition  to  insanity  are  factors  of  the  greatest 
importance. 

Marriage. — The  effects  of  marriage  upon  individuals 
who  are  mentally  unsound  are  usually  far  from  good.  In  the 
more  chronic  cases,  it  is  true,  there  is  sometimes  no  material 
change,  but  in  the  great  majority  of  instances  marriage  is  fol- 
lowed by  a  marked  exacerbation  of  the  symptoms,  culminating 
either  in  an  acute  outbreak  of  mania  or  a  profound  deepening 
of  the  depression,  as  the  case  may  be.  There  is  an  ill-founded 
and  utterly  unjustifiable  belief  current  among  the  laity  that 
many  forms  of  alienation  are  likely  to  be  benefited  by  mar- 
riage, and,  unfortunately,  not  a  few  members  of  the  medical 
profession  have  been  known  to  recommend  this  step  in  the  hope 
that  some  improvement  might  follow.  Such  a  procedure  can 
not  be  too  strongly  condemned.  The  literature  contains  not  a 
few  references  to  outbreaks  of  alienation  immediately  follow- 
ing marriage — the  so-called  nuptial  insanity;  and  Kraepelin 
in  his  text-book  has  classed  the  majority  of  such  cases  either 
among  the  manic-depressive  insanities  or  the  amentias.  Ober- 
steiner  31  distinguishes  two  groups  of  cases :      ( 1 )   Those  in 


81  Ueber  Psychoses  in  unmittelbarem  Anschluss  an  die  Verheiratung 
(Nuptiales  Irresein),  Jahrb.  f.  Psych,  u.  Neurol.,  Leipzig  u.  Wien,  19x12. 


200 


PSYCHIATRY 


which  a  previous  existing  alienation  is  made  more  pronounced 
and  first  becomes  recognized  by  the  physician  immediately  after 
marriage.  (2)  A  group  of  cases  in  which  the  symptoms  ap- 
parently develop  primarily.  Most  of  the  cases  in  the  second 
group  occur  in  nervous  run-down  females,  nearly  always  be- 
tween the  ages  of  19  and  27.  The  immediate  cause  is  undoubt- 
edly in  part  due  to  the  sexual  excitement  following  marriage, 
although  Obersteiner  rightly  says  that  several  other  factors 
must  also  be  taken  into  account.  Although  the  majority  of 
these  cases  have  been  noted  in  women,  nuptial  insanity 
occasionally  occurs  in  men.  Thus  in  one  of  our  male  patients, 
whose  history  is  given  later  on,  marriage  preceded  the  outbreak 
of  an  attack  of  dementia  prsecox.  In  the  clinical  examination 
of  these  cases  it  is  important  to  determine  whether  symptoms 
of  alienation  have  not  existed  in  a  mild  form  before  the  actual 
outbreak  of  the  more  acute  manifestations.  The  forms  of 
alienation  are  varied.  In  one  or  two  instances  acute  or  sub- 
acute confusional  delirious  states  have  been  reported  from 
which  the  patient  recovered  completely. 

Pregnancy  and  Parturition.32 — The  old  writers  were 
in  the  habit  of  speaking  of  puerperal  manias  and  puerperal 
melancholias,  as  if  these  mental  disturbances  were  in  a  sense 
to  be  regarded  as  entities.  Recent  clinical  investigations,  how- 
ever, have  clearly  shown  that  while  pregnancy,  parturition,  and 
lactation  may  be  regarded  as  inciting  causes,  they  are  in  no 
sense  to  be  associated  with  a  specific  form  of  alienation,  and 
that  the  mental  disturbances  cannot  be  differentiated  by  any 
specific  symptoms  from  those  of  other  psychoses.  It  is  now 
generally  conceded  that  practically  any  form  of  alienation  may 
begin  during  pregnancy,  the  puerperium,  or  the  period  of  lacta- 
tion. As  regards  their  relative  incidence  during  these  three 
periods  the  authorities  are  not  fully  agreed,  but,  making  allow- 
ance for  small  differences  in  percentages,  there  is  a  singular 
unanimity  of  opinion  among  both  older  and  later  writers  that 

82  Klix :  Ueber  die  Geistesstorungen  in  der  Schwangerschaft  und  im 
Wochenbett.  Halle  a/S.,  1904.  Williams,  J.  Whitridge :  Obstetrics.  New 
York,  1903. 


CAUSES    OF   INSANITY  207 

mental  disorders  make  their  appearance  more  frequently  dur- 
ing the  puerperium  than  during  the  period  of  lactation,  and 
are  still  more  rare  during  pregnancy.  The  following  statistics 
cited  by  Klix  may  be  taken  as  fairly  indicative  of  these  views : 

_  Puerperium  (within  T      .   .. 

Pregnancy  .  ,       „      ,  .      ,         Lactation 

six  weeks  after  labor) 

Schmidt   17.6  49.3  33-0 

Hoche  11.38  46.4  42.18 

That  normal  pregnancy  is  to  be  considered  a  factor  of 
eminent  importance  in  the  etiology  of  alienation  is  shown  by 
the  large  number  of  psychoses  which  appear  in  association  with 
childbirth  in  patients  with  a  bad  family  history,  in  the  more 
recent  statistics  the  figures  varying  from  47  to  32  per  cent. 
Moreover,  where  a  marked  predisposition  towards  alienation 
exists,  the  mental  break-down  is  most  apt  to  occur  early  in 
pregnancy,  less  often  at  full  term  or  within  six  weeks  of 
parturition,  and  least  frequently  during  the  period  of  lactation. 

As  regards  the  age  of  the  patients,  it  will  be  seen  that 
symptoms  of  alienation  appear  somewhat  rarely  in  pregnant 
women  before  the  twenty-fifth  year,  but  then  begin  to  be  en- 
countered with  increasing  frequency,  reaching  their  maximum 
incidence  between  the  thirtieth  and  fortieth  years.  Of  the 
cases  developing  before  parturition  the  majority  come  on  dur- 
ing the  latter  half  of  pregnancy;  and  as  a  general  rule  the 
earlier  the  alienation  becomes  apparent  during  pregnancy  the 
worse  is  the  prognosis.  Most  of  the  post-partum  psychoses 
come  on  within  the  first  fourteen  days  after  labor,  generally 
between  the  fourth  and  the  sixth  day.  Regarding  the  character 
of  these  psychoses  and  their  etiology  there  is  still  some  di- 
vergence of  opinion.  Some  authorities  maintain  that  every 
form  of  alienation  occurring  during  labor  or  the  puerperium  is 
immediately  the  result  of  an  infection,  but  this  sweeping  state- 
ment must  be  received  with  caution.  In  support  of  this  view 
is  the  fact  that  the  psychoses  that  make  their  appearance  at 
this  time  are  almost  always  accompanied  with  a  rise  of  tem- 
perature and  various  somatic  symptoms,  which  indicate  the 


208  PSYCHIATRY 

existence  of  an  infectious  process ;  and,  moreover,  there  is  often 
a  concomitant  mastitis,  parametritis,  pneumonia,  etc.  But 
admitting  that  many  of  the  cases  are  referable  to  some  form  of 
septic  infection,  it  is  a  noteworthy  fact  that  some  psychoses 
continue  long  after  the  subsidence  of  the  temperature  and  gen- 
eral somatic  symptoms.  Fiirstner  33  years  ago  described  an 
acute  hallucinatory  insanity  of  parturition,  a  form  of  aliena- 
tion which  began  with  a  prodromal  period  of  short  duration 
and  was  followed  by  a  period  of  active  hallucinosis.  Reference 
is  made  to  this  subject  under  the  head  of  acute  delirium  and 
amentia,  and  under  these  two  groups  undoubtedly  may  be 
classed  a  number  of  the  more  acute  forms  of  mental  disturb- 
ance which  occur  at  these  periods.  The  connection  of  septic 
processes  with  the  mental  disturbances  occurring  during  the 
period  of  lactation  is  a  subject  which  needs  to  be  further  in- 
vestigated. Whenever  signs  of  alienation  appear,  the  possi- 
bility of  an  infection  should  always  be  remembered  and  every 
effort  should  be  made  either  to  identify  or  exclude  this  factor. 
Moreover,  it  should  not  be  forgotten  that  fever  and  the  local 
septic  processes  are  not  always  parallel  phenomena  with  the 
psychic  disturbances,  and  this  fact  often  increases  the  diffi- 
culty of  making  a  diagnosis.  As  Klix  has  pointed  out,  pro- 
found disturbances  in  consciousness  appearing  at  the  beginning 
of  labor  should  at  once  arouse  the  suspicion  of  the  existence 
of  a  severe  septic  process  or  an  oncoming  eclamptic  seizure. 
The  mental  disturbances  which  occur  subsequent  to  the  period 
of  lactation  do  not  materially  differ  from  other  forms  of 
psychoses  and  need  not  be  dealt  with  in  detail  here. 

Anaemias. — In  cases  of  protracted  anaemia  we  meet  with 
changes  in  the  peripheral  as  well  as  in  the  central  nervous  sys- 
tem. Recently  these  lesions  have  been  studied  in  detail  for  the 
spinal  cord,  and  similar  alterations  are  said  to  exist  in  the 
brain.  Not  uncommonly  anaemic  patients  evince  a  marked 
irritability,  associated  with  more  or  less  indifference  to  their 


^Ueber  Schwangerschafts-  und  Puerperalpsychosen.     Arch.  f.  Psych., 
1875,  Bd.  v,  H.  2,  S.  505. 


CAUSES    OF   INSANITY  209 

surroundings;  and  although  they  are  apparently  hypersensi- 
tive for  certain  stimuli,  they  fail  to  respond  to  others.  These 
patients  are  apt  to  be  unsympathetic,  to  take  pessimistic  views, 
are  decidedly  anti-sociable  in  their  inclinations,  and  nearly  all 
show  subjective  defects  in  memory.  The  cases  that  have  been 
reported  in  which  pronounced  somatic  disturbances,  such  as  an 
unilateral  facial  paralysis,  transitory  hemiplegic  attacks, 
aphasic  symptoms,  the  Argyll-Robertson  pupil,  and  disturb- 
ances of  speech,  indicate  the  action  of  some  etiologic  factor 
other  than  anaemia. 

The  recent  literature  is  full  of  reports  of  mental  disturb- 
ances occurring  during  the  course  of  pernicious  anaemias.  The 
psychical  symptoms  are  general  impairment  of  the  intellectual 
faculties  characterized  by  a  slight  apathy  and  delay  in  the 
motor  reactions.  In  addition  to  these  defects  irritability  and 
exaltation  have  occasionally  been  mentioned.34 

The  importance  of  severe  anaemia  as  an  etiologic  factor 
in  various  forms  of  alienation,  as,  for  example,  in  certain  con- 
fusional  states,  the  so-called  collapse  delirium  and  amentia,  has 
been  frequently  emphasized.  Pontoppidan  35  and  Petren,36  in 
addition  to  the  symptoms  already  enumerated,  mention  deliri- 
ous and  confusional  states  which  develop  in  cases  of  pernicious 
anaemia  just  prior  to  death.  Marcus  37  reports  a  case  in  which 
the  symptoms  consisted  in  a  marked  irritability  with  some  ex- 
altation, followed  by  depression,  diminution  of  the  intellectual 
activities,  and,  finally,  marked  somnolence.  Later  the  patient 
developed  symptoms  that  were  similar  to  those  observed  in  the 
classical  type  of  paresis.  It  is  probable  that  these  last  mentioned 
manifestations  are  largely  referable  to  the  personal  predisposi- 
tion of  the  patient  towards  this  particular  form  of  alienation. 
It  is  not  at  all  unlikely  that  the  mental  symptoms  developing  in 


34  Marcus,  Henry :    Psychose  bei  pernicioser  Anamie.     Neurolog.  Cen- 
tralbl.,  1903,  16  Mai,  Nr.  10,  S.  453. 

35  Psychiatr.  forelaesn.  Kjobenhagen,  1892. 

38  Ryggmargs  forandringar  vid  pernicios  Anami.  Dissert.,  Stockholm, 

1895. 

87  Op.  cit. 

14 


210 


PSYCHIATRY 


cases  of  anaemia  depend  upon  some  toxin  that  acts  directly 
upon  the  central  nervous  system.38 

Fevers  and  Infectious  Processes. — The  part  played  by 
infectious  diseases  in  the  etiology  of  alienation  has  been  dis- 
cussed in  connection  with  the  fever  deliria,  and  need  not  be 
referred  to  again  in  the  present  chapter.  The  relation  of  the 
general  constitutional  diseases,  especially  tuberculosis,  to  alien- 
ation is  also  considered  elsewhere  more  in  detail.  The  mental 
state  of  tuberculous  patients  is  one  that  has  received  careful 
attention  from  numerous  observers.  The  old  belief  to  the 
effect  that  there  is  a  general  euphoria  present  in  certain  stages 
of  tuberculosis  is  an  hypothesis  which  has  not  been  confirmed 
by  careful  clinical  investigation.39  The  manner  of  life  and  a 
great  variety  of  other  conditions  in  a  measure  determine  the 
mental  state  of  many  tuberculous  patients,  although  a  certain 
degree  of  hopefulness  even  in  the  face  of  death  is  not  uncom- 
mon. On  the  other  hand,  it  has  been  frequently  shown  that 
various  forms  of  alienation — states  of  confusion  with  or  with- 
out hallucinations,  insane  ideas,  exaltation  and  depression, 
motor  restlessness,  etc. — may  be  associated  with  this  disease. 

The  occurrence  of  tuberculosis  in  the  insane  is  a  matter 
of  very  great  importance.  Fortunately,  the  hygienic  conditions 
which  now  prevail  in  many  hospitals  for  the  insane  and  the 
introduction  of  proper  clinical  methods  have  resulted  in  a  per- 
ceptible reduction  of  morbidity  and  mortality  from  this  disease. 
The  attempts  that  are  being  made  in  our  asylums  to  isolate 
tuberculous  patients  and  to  keep  them  as  much  as  possible  in 
the  open  air  cannot  be  too  highly  commended.  The  great  prev- 
alence of  tuberculosis  among  patients  suffering  from  certain 
forms  of  alienation — particularly  dementia  praecox — has  at- 
tracted special  attention. 

The  relation  of  syphilis  to  mental  disease  is  more  fully  dis- 
cussed in  the  chapter  on  alienation  associated  with  organic 
diseases  of  the  brain.    The  importance  of  this  etiological  factor 


38  Grawitz  :    Berliner  klin.  Wchnschr.,  1901,  Nr.  24. 

89  Letulle :   Etude  sur  la  psychologie  du  phtisique.    Arch,  de  med.,  1901. 


CAUSES    OF   INSANITY  211 

can  hardly  be  overestimated.  It  is  commonly  supposed  that 
the  luetic  poison  brings  about  the  formation  of  toxins  which 
have  a  markedly  deleterious  effect  upon  the  central  nervous 
system.  Individual  predisposition  also  seems  to  be  an  im- 
portant factor  in  determining  the  character  of  the  clinical 
picture.  That  the  ultimate  effects  of  the  poison  may  be  long 
delayed  becomes  evident  in  such  forms  of  alienation  as  demen- 
tia paralytica,  where  the  first  symptoms  are  noted,  on  an  aver- 
age, about  ten  years  after  the  primary  infection. 

Although  it  is  highly  probable  that  defective  metabolism 
plays  an  important  part  in  the  pathogenesis  of  alienation,  little 
is  known  upon  the  subject.  It  is  only  necessary  to  mention  in 
this  connection  the  forms  of  alienation  following  diseases  of 
the  thyroid  gland,  the  mental  conditions  associated  with  Addi- 
son's disease,  or  the  various  delirious  states  following  disturb- 
ances in  the  gastro-intestinal  tract.  Further  references  to  this 
subject  will  be  found  in  connection  with  the  discussion  of  dia- 
betes, gout,  and  changes  in  the  blood  in  their  relation  to  abnor- 
mal mental  states. 

The  important  part  played  by  toxic  substances  introduced 
into  the  organism  from  without — such  as  alcohol,  morphin, 
and  lead — and  the  relation  that  diseases  of  the  spinal  cord  and 
peripheral  nervous  system  bear  to  alienation  have  been  more 
fully  discussed  elsewhere  under  separate  heads. 

Gout. — Various  forms  of  mental  aberration  are  not  infre- 
quent in  families  whose  members  are  sufferers  from  gout. 
Minkowski's  40  studies,  however,  do  not  bear  out  the  view  that 
the  toxic  action  of  the  uric  acid,  a  diminution  in  the  oxidation 
processes,  or  an  alteration  in  the  alkalescence  of  the  blood  is 
the  cause  of  these  symptoms.  In  fact,  he  states  that  all  the 
explanations  hitherto  advanced  are  purely  hypothetical.  The 
symptomatology  of  the  milder  cases  is  in  a  measure  character- 
istic. The  patients,  unless  their  work  is  done  in  the  open  air, 
are  apt  to  be  irritable  and  easily  fatigued  mentally  and  physi- 


40  Die  Gicht.    Nothnagel's  Specielle  Pathologie  und  Therapie.     Bd.  vii, 
Theil  III. 


212  PSYCHIATRY 

cally.  In  addition  to  the  milder  neurasthenic  states  in  gouty- 
families  we  not  infrequently  meet  with  cases  of  mental  depres- 
sion generally  associated  with  neurasthenic  or  hysterical  mani- 
festations. More  marked  psychical  disturbances,  periods  of 
excitement,  delirious  states  associated  with  marked  rises  of 
temperature,  have  frequently  been  reported.  Of  particular 
interest  are  the  transitory  forms  of  alienation  which  follow 
an  attack  of  gout.  Berthier  41  collected  a  number  of  instances 
of  psychoses  in  gouty  individuals.  It  is  not  improbable,  how- 
ever, as  Crichton  Brown  maintains,  that  psychoses  only  occur 
in  such  gouty  individuals  as  have  previously  shown  a.  predispo- 
sition towards  alienation.  Some  of  the  psychoses  which  follow 
an  attack  may  be  either  the  results  of  alcoholic  or  lead  ence- 
phalopathy or  represent  true  ursemic  disturbances.  The  in- 
clination of  certain  patients  to  periods  of  depression  or  hypo- 
chondriasis associated  with  their  gouty  attacks  does  not 
necessarily  mean  that  the  mental  symptoms  are  specific,  since 
it  is  evident  that  the  mere  presence  of  pain  or  disablement 
might  be  sufficient  to  account  for  these  so-called  gouty  depres- 
sions. It  should  always  be  borne  in  mind  that  gout,  no  less 
than  any  other  disease,  may  be  an  important  factor  in  the 
etiology  of  insanity  without  being  the  sole  specific  cause. 

Diabetes  and  Glycosuria. — The  intimate  association 
that  exists  between  diabetes  and  various  disturbances  in  the 
peripheral  and  central  nervous  system  has  long  been  recog- 
nized, and  nearly  all  the  text-books  on  medicine  give  somewhat 
full  descriptions  of  the  many  nervous  and  mental  symptoms 
which  may  be  encountered  in  diabetic  patients.  That  these 
disturbances  are  in  part  the  result  of  an  autointoxication  there 
seems  to  be  little  doubt,  but  the  various  theories  advanced  to 
explain  the  character  of  the  changes  in  the  tissues  are  by  no 
means  satisfactory.  Kussmaul's  opinion  that  the  symptoms 
might  be  the  result  of  an  autointoxication  due  to  acetone  has 
not  been  confirmed  either  by  clinical  observation  or  by  experi- 
ments upon  animals.       Equally  unsatisfactory  has  been  the 

41  Annales  Medico-psychologiques,  Paris,  1869. 


CAUSES   OF  INSANITY  213 

hypothesis  that  /3-oxybutyric  acid,  and  not  acetone,  is  the 
cause  of  the  disturbance.  The  supposed  acidity  of  the  blood, 
which  was  regarded  as  the  immediate  cause  of  the  symptoms, 
has  been  practically  negatived  by  the  observations  of  Klemp- 
erer  and  others. 

The  disturbances  of  the  functions  of  the  brain  which  may 
occur  during  diabetes  are  manifold.  A  mild  form  of  depres- 
sion with  lack  of  initiative,  extreme  mental  and  physical 
fatigue  following  slight  exertion,  and  a  considerable  degree  of 
intellectual  torpor  are  not  infrequently  noted.  The  condition 
known  as  narcolepsy — the  patient  showing  a  marked  tendency 
to  fall  asleep  at  all  times — should  also  be  mentioned.  Some- 
times the  periods  of  depression  are  broken  by  states  of  motor 
restlessness  and  some  degree  of  exhilaration,  and  occasionally 
we  meet  with  periods  of  delirium,  such  as  that  recorded  in  the 
following  history,  to  which  my  attention  was  called  by  Dr. 
Futcher.  This  patient  suffered  from  active  fallacious  sense 
perceptions,  and  his  case  is  also  of  interest  in  that  it  shows  the 
difficulty  that  sometimes  exists  in  the  diagnosis  of  these  con- 
ditions. 

Johns  Hopkins  Hospital,  Medical  No.  9326.  General  No.  24,955.  Male, 
aged  48.  German.  Clerk  in  commission  house.  Admitted  December  10, 
1898.  Discharged  January  16,  1899.  Improved.  Diagnosis :  Diabetes 
mellitus. 

Family  History. — Negative. 

Personal  History. — On  account  of  the  patient's  mental  state  the  history- 
was  obtained  from  his  friends  and  was,  therefore,  somewhat  unsatisfactory. 
No  history  of  previous  severe  illness  was  obtained,  except  of  a  malarial 
attack  lasting  two  months,  a  year  before  admission.  As  a  young  man  he 
was  somewhat  dissipated,  but  during  the  last  three  or  four  years  he  has  been 
more  temperate.  There  is  a  history  of  chancre,  but  that  of  a  secondary 
eruption  is  indefinite.  Recently  the  patient  has  been  suspicious  of  his  wife 
receiving  attention  from  other  persons ;  but  whether  any  grounds  for  these 
ideas  existed  is  not  known. 

Present  Illness. — In  January,  1898,  the  patient  had  an  attack  similar  to 
the  present  one  and  has  never  been  quite  well  since.  At  that  time  a  diag- 
nosis of  Bright's  disease  was  made  by  his  physician.  Eight  days  prior  to 
his  admission  to  the  hospital  the  patient  began  to  complain  of  headache  and 
dizziness.  These  symptoms  were  soon  followed  by  disturbances  in  con- 
sciousness and  on  the  day  before  admission  by  illusions.  For  three  or  four 
days  prior  to  admission  the  patient  was  very  drowsy  and  slept  a  great  deal 
of  the  time. 


214 


PSYCHIATRY 


Condition  on  admission:  Well  built  man.  Respiration  slow  and 
labored,  very  irregular  in  rhythm  and  fulness.  Face  quite  blue,  cyanosis 
also  marked  in  hands  and  fingers.  Pulse  ioo  to  the  minute ;  of  small  vol- 
ume ;  tension  higher  than  normal.  Eyes :  Pupils  react  equally  and  readily 
to  light  and  accommodation.  Lungs :  Nothing  abnormal.  Heart :  Area 
of  cardiac  dulness  diminished.  The  second  aortic  sound  is  accentuated. 
While  the  patient  was  being  conveyed  from  the  dispensary  to  the  ward  he 
fell  asleep  in  a  chair  and  could  not  be  aroused.  Later,  on  the  same  day, 
his  appearance  was  suggestive  of  diabetic  coma.  A  specimen  of  urine 
drawn  through  the  catheter  was  very  acid,  specific  gravity  1037,  showed  a 
faint  trace  of  albumin,  6  per  cent,  of  sugar,  and  an  abundance  of  urates. 
On  December  13  the  patient  became  actively  delirious,  boisterous,  and  had 
illusions  relating,  as  a  rule,  to  his  former  profession.  Diacetic  acid  and 
acetone  were  found  in  the  urine.  There  was  no  /5-oxybutyric  acid  in 
the  fermented  urine. 

On  December  16  the  patient  was  less  delirious,  but  on  the  17th  it  was 
necessary  to  place  him  again  under  restraint.  On  the  21st  it  was  noted  that 
his  condition  still  remained  unchanged. 

January  1 :  The  patient  became  much  more  tractable  and  was  able  to 
talk  slowly  and  fairly  rationally.  January  2 :  The  urine  was  free  from 
sugar  and  acetone,  but  at  midnight  he  became  wildly  delirious,  jumping 
up  in  bed,  talking  irrationally,  and  at  times  being  very  maniacal.  Next 
morning  (January  3)  the  patient  was  again  quiet.  January  4:  Sugar  had 
reappeared  in  the  urine.  January  6 :  The  patient  was  perfectly  docile  and 
tractable.  On  January  9  he  had  an  attack  of  violent  excitement.  On 
January  14  there  was  a  sudden  rise  of  temperature  to  103.20  F.  On  the 
16th  he  was  somewhat  quieter  and  was  removed  at  the  request  of  his 
friends  to  his  home.  No  further  notes  on  the  condition  of  the  patient  could 
be  obtained,  but  it  was  discovered  that  he  died  at  some  date  (not  known) 
previous  to  January,  1903. 

Another  important  group  of  mental  cases,  sometimes 
noted  in  connection  with  diabetes,  are  those  described  by  Lau- 
denheimer 42  as  instances  of  pseudo-paresis.  In  these  forms 
the  disturbances  in  the  attention,  defects  in  associative  memory, 
occasional  interference  with  the  functions  of  speech  and  loco- 
motion, various  peripheral  paralyses,  and  impairment  of  the 
light  reflexes  render  the  differential  diagnosis  from  true  pare- 
sis exceedingly  difficult.  Generally,  however,  they  can  be  iden- 
tified on  account  of  the  improvement  in  the  symptoms  follow- 
ing the  disappearance  of  the  sugar  from  the  urine. 


Arch.  f.  Psych.,  xxix,  2.     Berl.  klin.  Wchnschr.,  1898,  21. 


CAUSES    OF   INSANITY  215 

Cardiac  and  Vascular  Disease.43 — Disturbances  in  the 
circulation  are  not  uncommonly  followed  by  or  associated  with 
anomalies  in  the  mental  life.  Maudsley  long  ago  advanced  the 
interesting  speculation  that  were  the  heart  of  one  man  placed 
in  the  body  of  another  the  exchange  would  probably  not  seri- 
ously interfere  with  the  circulation  of  their  blood,  but  might 
make  a  real  difference  in  the  temper  of  their  minds;  and  this 
hypothesis  would  seem  to  receive  daily  confirmation  from  the 
observations  in  the  clinic.  As  Head  44  has  shown,  the  mental 
changes  associated  with  anomalies  in  the  heart's  action  may 
be  caused  by  variations  in  the  cerebral  blood  supply,  since  we 
often  encounter  a  delirious  condition  associated  with  cardiac 
insufficiency  or  with  changes  due  to  altered  vascular  condi- 
tions. Mental  disturbances  may  be  the  immediate  result  of  the 
anomalies  in  circulation,  or  may  develop  secondarily  by  lower- 
ing the  resistance  of  the  organism  so  that  the  effects  of  such 
toxic  substances,  as  alcohol  or  the  products  of  autointoxication, 
are  less  easily  combated. 

These  abnormal  mental  states  connected  with  disturbances 
in  the  cardiac  functions  vary  greatly  in  severity  as  well  as  in 
character.  In  the  milder  forms  they  are  limited  to  slight 
changes  in  the  organic  sensibility,  and  the  patient  merely  be- 
comes aware  of  the  increased  or  irregular  cardiac  action,  his 
consciousness  of  it  rendering  him  depressed  and  restless.  In 
other  states  the  depression  is  more  marked;  the  individual 


43  D' Astros :  Etude  sur  l'etat  mentale  et  les  troubles  psychiques  des 
cardiaques.  These  de  Paris,  1881.  Mickle,  J. :  On  Insanity  in  its  relation 
to  Cardiac  and  Aortic  Disease.  London,  1888.  Fauconneau :  De  la  folie 
d'origine  cardiaque.  These  de  Paris,  1900.  Huchard :  Le  cerveau  car- 
diaque.  Bull,  med.,  1891.  Dobrotsworski,  S. :  Les  maladies  du  cceur 
comme  cause  des  psychoses.  Conference  a  la  clin.  neurol.  de  Petersbourg, 
10  Decembre,  Vratch,  1899,  p.  318.  Fischer,  J. :  Ueber  Psychosen  bei  Herz- 
kranken.  Allg.  Ztschr.  f.  Psych.,  Bd.  liv,  H.  6,  S.  1060.  Eichhorst: 
Deutsche  med.  Wchnschr.,  28  Juni,  1898.  Langdon,  F.  W. :  Cardio- 
vascular and  Blood  States  as  Factors  in  Nervous  and  Mental  Disease.  Cin- 
cinnati Lancet-Clinic,  May  7,  1904.  Gamble,  Cary  B. :  Johns  Hopkins 
Hosp.  Bull.,  vol.  xv,  1904. 

44  Certain  Mental  Changes  that  accompany  Visceral  Disease.  Brain, 
Part  III,  1901,  p.  346. 


2i6  PSYCHIATRY 

begins  to  be  suspicious,  sometimes  only  of  certain  individuals, 
although  in  other  cases  this  feeling  is  more  general.  Not  infre- 
quently hallucinations  are  noted  in  the  milder  cases,  which, 
however,  are  generally  recognized  by  the  patient  as  fallacious 
sense  perceptions.  At  first  they  are  apt  to  be  vague  in  char- 
acter and  ill-defined,  but  as  the  trouble  increases  or  as  the  ideas 
become  more  persistent,  the  appreciation  of  their  fallaciousness 
may  be  lost.  In  some  cases,  instead  of  depression,  a  state  of 
exaltation  or  exhilaration  is  met  with.  The  importance  of 
these  circulatory  anomalies  in  cases  of  mental  depression  and 
apprehensiveness  has  been  more  fully  investigated-  by  Rein- 
hold,45  and  the  subject  will  be  again  referred  to  when  we  come 
to  discuss  senile  melancholia.  Acute  dilatation  of  the  heart 
has  often  been  noted  in  several  of  the  more  acute  psychoses, 
particularly  the  febrile  deliria  and  the  acute  delirium  and  amen- 
tia. Recent  observations  go  to  show  that  cardiac  changes  of 
some  importance  may  take  place  during  the  acute  onset  of  some 
of  the  chronic  psychoses,  such  as  dementia  prsecox,  manic- 
depressive  insanity,  and  dementia  paralytica.  In  the  last,  as 
well  as  in  other  conditions,  marked  changes  in  the  cardiac 
muscle  are  relatively  common.  The  mental  disturbances  con- 
nected with  disorders  of  the  vascular  system  are  referred  to 
more  in  detail  in  the  discussion  of  arterio-sclerosis  as  well  as 
of  certain  other  morbid  conditions — alcoholism,  general  pare- 
sis, the  senile  psychoses,  and  others — which  are  often  com- 
plicated by  marked  arterial  changes.  Evidences  of  changes 
in  the  superficial  circulation  are  frequently  met  with  in  insane 
patients.  Thus,  in  cases  of  dementia  prsecox  the  patients  have 
a  peculiar  pasty  appearance  and  at  times  a  more  or  less  pro- 
nounced degree  of  cyanosis.  In  the  maniacal  states  we  en- 
counter manifestations  pointing  to  the  existence  of  a  relaxed 
vasomotor  condition.  Thus  a  pronounced  degree  of  der- 
matographia  is  not  uncommon.  The  relation  of  the  blood- 
pressure  to  the  various  mental  states  has  lately  been  the  sub- 
ject of  painstaking  study,  but  the  results  thus  far  published  are 

45  Munch,  med.  Wchnschr.,  1894,  16. 


CAUSES    OF   INSANITY  217 

still  open  to  criticism,  and  all  of  these  observations  must  as  yet 
be  accepted  with  caution.  Dunton,46  who  conducted  his  experi- 
ments on  the  changes  of  blood-pressure  in  relation  to  states  of 
depression  and  excitement  with  the  greatest  possible  care,  ad- 
mits that  the  instrument  with  which  the  observations  were 
made  did  not  give  results  which  he  could  regard  as  entirely 
reliable.  Indeed,  the  data  obtained  are  so  uncertain  that  the 
blood-pressure  records  can  not,  as  a  rule,  be  accepted  as  afford- 
ing any  definite  indications  for  treatment.  In  a  general  way, 
however,  it  may  be  said  that  the  evidence  so  far  accumulated 
points  to  the  existence  of  a  subnormal  blood-pressure  in  states 
of  excitement  and  an  increase  in  states  of  mental  depression. 
Of  course,  where  other  additional  factors  have  to  be  taken  into 
account  the  results  are  even  more  unsatisfactory. 

Mental  Disturbances  in  Hepatic  Disease. — Disturb- 
ances in  the  hepatic  functions  are  not  rarely  associated  with  or 
followed  by  aberration.47  A  full  review  of  this  subject  by  Bal- 
let,48 with  bibliography,  has  recently  appeared.  The  recorded 
mental  symptoms  furnish  a  great  variety  of  clinical  pictures,  of 
particular  importance  being  the  states  of  somnolence  and 
stupor  that  not  infrequently  develop  during  the  terminal  stage 
of  hepatic  disease.  In  the  milder  cases  the  faculty  of  attention 
becomes  defective ;  actual  distractibility,  the  result  of  increased 
sensory  impressionability,  is  not  marked,  but  the  patient  seems 
unable  to  direct  his  mental  energies  persistently  for  any  given 
length  of  time  in  one  direction.  In  other  words,  the  attention 
is  not  actively  diverted,  but  as  the  result  of  the  lethargic  condi- 
tion simply  lapses.  In  another  group  of  cases  where  marked 
disturbances  in  the  hepatic  functions  were  noted,  the  patients 
were  more  or  less  excited  and  showed  evidences  of  speech  com- 
pulsion, psychomotor  excitability,  auditory  and  visual  hallu- 
cinations, and  more  or  less  indefinite  and  unstable  insane  ideas. 


46  Some  Observations  upon  Blood-Pressure  in  the  Insane.     Trans,  of 
American  Medico-Psychological  Association,  1903. 

47Delaye  and  Foville:    Nouveau  Journ.  de  med.,  1821,  Septembre. 
48  Ballet :   Traite  de  la  pathologie  Mentale,  Paris,  1903,  p.  478. 


2i8  PSYCHIATRY 

Such  cases  are  not  to  be  regarded  as  the  result  of  hepatic  dis- 
ease by  itself,  but  of  a  series  of  complications.  After  a  period 
of  brief  excitement  the  patient  may  pass  more  or  less  rapidly 
into  a  state  of  stupor  which  generally  ends  in  death  (delirium, 
coma  hepaticum).  The  hepatic  stupor  or  coma  is  far  less  apt 
than  the  ursemic  or  diabetic  form  to  show  evidence  of  remis- 
sion, and  a  complete  recovery  seldom,  if  ever,  occurs.49  When 
the  excitement  is  of  a  mild  grade  and  deep  stupor  does  not 
intervene,  the  psychic  anomalies  may  persist  for  weeks  or 
months,  after  which  the  patients  may  gradually  recover. 

Temporary  mental  disturbances  are  not  infrequently  noted 
after  operations  upon  the  common  bile-duct.  Dr.  J.  M.  T. 
Finney  informs  me  that  in  the  records  of  ioo  operations 
upon  the  biliary  passages  the  occurrence  of  a  peculiar  tran- 
sitory delirium  has  been  noted  in  about  10  per  cent,  of  the 
cases.  These  mental  disturbances  develop  during  the  course 
of  convalescence  after  the  bile-passages  have  been  drained,  and 
are  apt  to  run  rather  a  characteristic  course,  frequently  lasting 
a  fortnight  and  then  disappearing  without  leaving  any  re- 
siduary mental  disturbances.  The  severity  of  the  condition 
varies  from  a  mild  temporary  aberration,  accompanied  by  diz- 
ziness and  peculiar  sensations  in  the  head,  to  a  wild  delirium. 
As  a  rule,  the  nocturnal  exacerbations  are  marked.  The  first 
symptoms  of  mental  aberration  generally  appear  about  the  end 
of  the  first  week  after  the  operation,  and  consist  in  a  slight 
dizziness  or  dull  feeling,  frequently  accompanied  by  mental 
depression,  confusion  of  ideas,  hallucinations,  both  visual  and 
auditory,  and  various  forms  of  delusions.  The  symptoms 
often  develop  at  the  time  at  which  the  bile  begins  to  leak 
around  the  drainage-tube  and  flow  over  the  surface  of  the 
wound,  at  this  time  unprotected  by  granulations.  It  may  be 
said  that  the  development  of  the  mental  anomalies  seems  to 
bear  some  definite  relationship  to  the  activity  of  the  kidneys, 
inasmuch  as  at  the  time  of  the  delirium  some  diminution  in 


48  Quincke  u.  Hoppe-Seyler.    Die  Krankheiten  der  Leber.    Nothnagel's 
Spec.  Pathol,  u.  Therap.,  Wien,  1899. 


CAUSES    OF    INSANITY  219 

the  amount  of  urine  passed  and  the  presence  of  albumin  and 
tube-casts  have  generally  been  noted. 

Finney  believes  that  the  following  conditions  play  an  im- 
portant part  in  the  pathogenesis  of  the  delirium : 

(1)  An  abnormal  condition  of  the  bile  due  to  derange- 
ment of  the  hepatic  functions. 

(2)  A  possible  absorption  of  toxic  products  from  the 
presence  of  bacteria. 

(3)  A  predisposition  to  nervous  and  mental  disturbances, 
causing  an  increased  susceptibility  in  the  abnormal  reactions 
for  certain  toxic  products. 

Undoubtedly  many  of  these  symptoms  referred  to  are  the 
result  of  an  intoxication  due  to  the  accumulation  in  the  system 
of  substances  the  result  of  imperfect  metabolism.  It  is  diffi- 
cult to  differentiate  the  pure,  uncomplicated  cases  of  hepatic 
disorder  from  those  in  which  such  etiological  factors  as  alco- 
holism, syphilis,  or  tuberculosis  are  added. 

The  prognosis  depends  in  a  measure  upon  the  nature  and 
extent  of  the  disease.  The  toxic  products  that  cause  the  symp- 
toms may  be  derived  from  more  than  one  source,  and  are  either 
manufactured  directly  by  the  liver  or  absorbed  from  the  intes- 
tinal tract.  Pathological  changes  in  the  liver  are  noted  in 
many  of  the  psychoses. 

Nephritis.50 — Disturbances  in  the  functioning  of  the 
kidneys  are  frequently  found  complicating  the  course  of  vari- 
ous psychoses  and  have  been  made  the  subject  of  a  special 
study  by  numerous  investigators.  Although  some  authors 
maintain  that  there  is  a  specific  form  of  alienation  associated 
with  Bright's  disease,  the  evidence  adduced  is  far  from  con- 
clusive.    The  abnormalities  in  the  urinary  secretion,   found 

60  Hagen :  Des  maladies  des  reins  considerees  comme  causes  d'alienation 
mentale.  Allg.  Ztschr.  f.  Psych,  u.  psych. -gericht.  Medizin,  xxxviii,  1. 
Bouvat :  Essai  sur  l'uremie  delirante.  Th.  de  Lyon,  1883.  Dieulafoy :  De 
la  folie  brightique.  Soc.  med.  d.  hop.,  10  Juin,  1883.  Contrib.  a  l'etude 
clin.  et  experim.  de  la  maladie  de  Bright  sans  albuminuric  Soc.  med.  d. 
hop.,  11  Juin,  22  Octobre,  1886.  Raymond:  Sur  certains  delires  simulants 
la  folie  survenus  dans  le  cours  des  nephrites  chroniques.  Arch.  gen.  de 
med.,  Mars,  1882. 


220  PSYCHIATRY 

associated  with  psychoses,  in  the  vast  majority  of  cases  are  to 
be  regarded  as  the  result  rather  than  the  cause  of  the  aliena- 
tion. The  delirium  that  occurs  in  uraemia  has  certain  specific 
characteristics  which  are  fairly  distinctive,  but  even  in  this 
connection  it  is  scarcely  permissible  to  speak,  as  do  certain  of 
the  French  writers,  of  a  specific  urasmic  delirium.  Although 
the  urine  has  been  carefully  examined  in  a  great  variety  of 
psychoses,  no  very  definite  results  have  been  obtained.  After 
careful  analyses  in  a  large  number  of  cases  of  recurrent  mania 
and  melancholia  Pilcz  was  able  to  arrive  at  the  following  not 
very  satisfactory  conclusions:  In  many  individuals,  who  dur- 
ing the  period  of  remission  showed  no  abnormal  condition  of 
renal  secretion,  at  the  time  of  the  attack  the  urine  contained  a 
variety  of  abnormal  chemical  constituents,  but  the  results  of 
the  analyses  did  not  in  any  sense  show  anything  specific  of  the 
condition.  It  was,  however,  found  that  the  characteristics  of 
the  urine  during  a  given  period  of  either  excitement  or  depres- 
sion were  fairly  constant  for  the  same  individual. 

Gastro-intestinal  Disturbances. — Regarding  the  dis- 
turbances in  the  gastro-intestinal  tract  and  their  relation  to 
forms  of  alienation  very  little  is  known.  That  the  former  are 
frequently  associated  with  various  forms  of  mental  disorders  is 
a  matter  of  common  clinical  experience,  but  the  relation  that 
they  bear  to  the  alienation  is  a  matter  of  conjecture.  Von 
Wagner51  assumed  that  in  certain  forms  of  acute  mental  dis- 
ease there  was  an  autointoxication  due  to  defective  metab- 
olism; and  the  same  observer  was  able  to  demonstrate  the 
increase  in  the  urine  of  indican  as  well  as  of  acetone.  In  the 
case  reported  by  Raimann  52  the  symptom-complex  resembling 
Korsakow's  syndrome  was  noted  in  a  patient  who  died  and  in 
whom  at  autopsy  were  found  multiple  lymphosarcomata  of  the 
small  intestine.     A  few  other  cases  somewhat  similar  in  char- 


61  Ueber  Psychosen  durch  Autointoxication  vom  Darm  aus.  Jahrb.  f. 
Psych.,  1002,  xxii,  177. 

52  Raimann,  Emil :  Ein  Fall  von  Cerebropathia  psychica  toxaemica 
(Korsakow)  Gastrointestinalen  Ursprunges.  Monatsschr.  f.  Psych,  u. 
Neurol.,  1902,  October,  Bd.  xii,  H.  4,  S.  329. 


CAUSES    OF   INSANITY  221 

acter  have  been  reported  in  the  literature.  That  there  is  a 
marked  defect  in  the  functions  of  the  stomach  and  intestines 
in  very  many  cases  of  alienation  is  a  matter  of  common  clinical 
experience,  as,  for  example,  in  cases  of  dementia  praecox  and 
manic-depressive  insanity.  Moreover,  milder  forms  of  mental 
depression,  such  as  hypochondriasis,  are  not  uncommonly 
noted  in  connection  with  gastro-intestinal  disturbances. 

Migraine. — Not  infrequently  attacks  of  migraine  are 
complicated  by  elementary  psychic  disturbances.53  In  such 
cases  it  is  not  improbable  that  the  symptoms  of  mental  aberra- 
tion are  indicative  of  the  existence  of  a  complicating  neurosis, 
such  as  epilepsy  or  hysteria  gravis,  and  are  not  in  any  sense 
specific.  Von  Krafft-Ebing,  referring  to  the  occurrence  of  at- 
tacks of  migraine  in  individuals  who  are  subject  to  epilepsy, 
says  that  in  these  cases  we  have  to  do  with  an  ophthalmic  or 
sensory  disturbance  of  the  Jacksonian  type,  in  which  the  visual 
aurse  precede  the  attack.  These  cases  are  not  infrequently 
referred  to  as  instances  of  epileptic  migraine  or  migrainous 
epilepsy.  The  psychical  disturbances  are  usually  transitory. 
In  some  instances  attacks  of  migraine  seem  to  be  associated 
with  hysterical  seizures,  and,  as  von  Krafft-Ebing  has  pointed 
out,  the  converse  may  also  be  true.  In  rare  cases,  together 
with  the  pain,  definite  visual  hallucinations  are  present.  The 
amnesic  aphasia,  that  frequently  occurs,  may  last  from  a 
few  seconds  to  half  an  hour.  Paresthesias  associated  with 
hemicrania  are  sometimes  met  with.  During  the  attack 
there  is  some  disturbance  of  speech  and  a  diminution  in  the 
pupillary  reflexes.  Severe  psychoses,  however,  are  not  com- 
mon, a  fact  which  von  Krafft-Ebing  thinks  is  indicative  of 
their  etiological  complexity,  although  Mingazzini  and  Pacetti 
hold  a  contrary  opinion  54  and  believe  that  the  hysterical  symp- 
toms in  all  cases  are  to  be  regarded  merely  as  complications. 


63  V.  Krafft-Ebing :  Arbeiten  aus  dem  Gesammtgebiet  der  Psychiatrie 
und  Neuropathologie,  Heft  i.  Ueber  Migranepsychosen.  Jahrbiicher  f. 
Psych,  u.  Neurol.,  Bd.  xxi,  H.  i  u.  2,  1902. 

54  Riv.  sper.  d.  freniatria,  25,  fasc,  2,  3,  4. 


222  PSYCHIATRY 

The  defects  in  memory  vary  in  intensity  from  the  milder  to 
the  more  severe  amnesias. 

Mental  Disturbances  in  Chorea. — Not  infrequently 
in  cases  of  Sydenham's  chorea  symptoms  of  mental  aberration 
appear  and  are  characterized  by  emotional  irritability  and  rapid 
changes  in  the  mood.  Attention  was  originally  directed  in  de- 
tail to  these  disturbances  by  Marcel,55  although  references  to 
the  subject  of  even  an  earlier  date  56  are  found  in  the  literature. 

In  addition  to  the  above-mentioned  psychic  anomalies, 
choreic  patients  frequently  suffer  from  various  kinds  of  obses- 
sions, while  in  the  protracted  cases  the  various  forms  of  psy- 
chic tic  are  apt  to  develop.  This  latter  symptom  shows  itself  in 
an  uncontrollable  impulse  to  perform  certain  acts,  to  touch  ob- 
jects, to  count,  etc.  The  mental  aberration  in  these  cases  is  of 
all  gradations,  from  the  milder  forms  of  psychasthenia  to  much 
more  profound  disturbances.  These  patients  are,  as  a  rule, 
markedly  impressionable  and  exceedingly  capricious,  being 
turned  about  by  every  whim.  They  become  moody,  morose, 
exceedingly  depressed  mentally,  and  on  little  or  no  provocation 
change  with  great  rapidity,  becoming  nervously  animated  and 
unduly  elated.  The  defects  in  the  intellectual  functions,  except 
in  the  delirious  states,  as  a  rule,  depend  upon  the  lapse  in  mem- 
ory and  attention.  The  consciousness  of  their  nervousness 
makes  these  patients  at  times  appear  indolent  and  lazy.  In 
some  cases  57  there  is  a  marked  transitory  state  of  confusion, 
associated  with  great  motor  restlessness,  and  during  this  period 
fallacious  sense  perceptions  are  common.  Visual  hallucina- 
tions not  infrequently  occur,  particularly  just  before  the  patient 
falls  asleep,  and  are  apt  to  be  more  or  less  terrifying  in  char- 
acter, the  forms  assumed  being  those  of  horrible-looking  ani- 
mals, people,  etc.  These  may  persist,  and  during  sleep  the 
patient  may  suffer  from  nocturnal  terrors.  Visual  hallucina- 
tions are  the  most  common,  but  the  visual,  haptic,  and  erotic 

55  Memories  de  l'Acad.  de  Medecine,  1859. 
68  Plat,  1614. 

"Mobius:     Neurolog.    Beitrage,    H.    2,    S.    129    ff.      Munch,    med. 
Wchnschr.,  1892,  Nr.  51  u.  52. 


CAUSES    OF   INSANITY  223 

forms  also  occur.  In  a  few  cases  the  patients  pass  into  a  stupor- 
ous state.  Ziehen,  under  the  head  of  choreic  psychic  changes, 
describes  these  milder  forms  of  aberration  as  typical.  Cases 
occurring  during  pregnancy  (chorea  gravidarum)  are  charac- 
terized by  great  severity  of  the  motor  disturbances  and  by 
periods  of  intense  excitement  and  exhaustion.  In  some  in- 
stances the  disease  is  complicated  by  hysterical  symptoms  and 
not  rarely  is  a  complication  of  epilepsy. 

Bradley  58  has  reported  a  case  of  chorea  insaniens  with 
pathological  findings  at  autopsy.  There  were  marked  degenera- 
tion of  the  ganglion  cells,  "  organized  mitral  vegetations,  con- 
gested hemolymph  glands,  arterial  hypoplasia,  an  apparently 
actively  functioning,  persistent  thymus,  and  mesenteric  lym- 
phatic hyperplasia." 

The  treatment  for  these  cases  is  that  indicated  for  chorea, 
in  addition  to  the  employment  of  means  for  the  relief  of  the 
mental  disturbances :  a  fluid  diet,  rest  in  bed,  and  warm  baths 
or  packs.  In  cases  in  which  the  motor  unrest  or  aberration  is 
very  marked  sedatives  may  be  employed — paraldehyde,  amy- 
lene  hydrate,  trional,  etc.  These  drugs,  however,  should  be 
used  with  great  caution. 

Huntington's  Chorea.— In  the  so-called  degenerative 
chorea  the  mental  changes,  as  a  rule,  are  much  more  marked 
than  in  the  ordinary  type.  Not  infrequently  the  patients 
are  subject  to  attacks  of  depression,  which  gradually  become 
more  frequent,  until  finally  there  are  no  lucid  intervals,  and  in 
addition  the  sufferers  show  a  marked  degree  of  mental  reduc- 
tion, becoming  apathetic  and  indifferent.  Despite  the  apathy 
and  intellectual  impairment,  however,  such  individuals  often 
show  a  considerable  degree  of  emotional  instability,  which 
manifests  itself  in  frequent  outbursts  of  temper.  The  memory, 
as  a  rule,  is  greatly  impaired.  The  intellectual  defect  becomes 
apparent  early  in  the  disease.  The  rapidity  with  which  it  pro- 
gresses varies  considerably.  In  some  cases  ideas  of  persecu- 
tion, alternating  with  varying  degrees  of  euphoria,  may  de- 

68  Am.  Journ.  Insan.,  vol.  lx,  No.  4,  1904. 


224 


PSYCHIATRY 


velop.  As  Wollenberg 59  has  stated,  there  is  no  exact 
parallelism  between  the  mental  and  the  physical  symptoms.  In 
cases  in  which  the  motor  symptoms  are  greatly  exaggerated  it 
does  not  necessarily  follow  that  the  mental  impairment  is  pro- 
found. In  the  case  reported  by  Rusk,60  which  is  important  on 
account  of  the  detailed  history,  choreiform  movements  had 
been  noted  for  seven  years  prior  to  the  appearance  of  the  men- 
tal symptoms.  Gradually  both  the  physical  and  the  mental 
symptoms  became  worse  and  the  patient  finally  died  from  an 
intercurrent  complication.  Recent  autopsies  have  not  con- 
firmed the  views  formerly  entertained  that  a  diffuse  interstitial 
encephalitis  exists  in  such  cases.  As  Rusk  points  out,  there  is 
not  sufficient  evidence  for  assuming  the  existence  of  an  inflam- 
matory condition.  The  organic  lesion  consists  chiefly  in  a 
marked  increase  of  the  neuroglia. 

The  disease,  as  is  well  known,  has  a  marked  tendency  to 
recur  in  families.  Although  it  has  been  said  that  it  generally 
makes  its  appearance  about  middle  life,  Heilbronner 61  main- 
tains that  it  shows  a  tendency  to  recur  in  every  generation  at 
an  earlier  period  than  in  the  one  preceding.  The  treatment  is 
purely  symptomatic. 


59  Wollenberg :  Chorea.  NothnageJ's  Spec.  Pathologie  und  Therapie, 
Bd.  xii,  Theil  II,  Abth.  3. 

80  Rusk,  Glanville  Y. :  A  Case  of  Huntington's  Chorea  with  Autopsy. 
Am.  Journ.  Insan.,  1902,  lix,  No.  1. 

81  Heilbronner :  Ueber  eine  Art  progressiver  Hereditat  bei  Hunting- 
ton'scher  Chorea.  Arch.  f.  Psych,  u.  Nervenkrankh.,  Berlin,  1903,  Bd. 
xxxvi,  H.  3. 


CHAPTER      VIII 

THE    PRINCIPLES     CONCERNED     IN     A     PROVISIONAL     CLINICAL 
GROUPING   OF    MENTAL  DISEASES  * 

Any  attempt  to  form  a  provisional  grouping  of  mental 
disorders,  to  be  successful,  must  be  based  upon  the  considera- 
tion of  a  number  of  different  factors.  In  the  first  place,  it  is 
of  prime  importance  for  physicians  to  realize  that  in  a  study  of 
alienation  we  are  not  dealing  with  definite  disease  entities,  such 
as  typhoid  fever  or  pneumonia,  where  a  direct  causal  relation- 
ship between  the  exciting  etiological  factor  and  the  symptoms 
of  the  disease  is  demonstrable.  In  typhoid  fever  or  meningitis 
the  nature  of  the  morbid  process  is  more  or  less  definite,  and 
the  natural  history  of  these  and  similar  disorders  has  been 
clearly  and  accurately  described.  In  a  consideration  of  even 
the  simplest  forms  of  alienation,  however,  there  are  so  many 
indefinite  and  ill-defined  factors  to  be  considered  that  the  prob- 
lems connected  with  the  differentiation  of  disease  types  at  once 
become  difficult  and  complex.  Before  considering  definitely  the 
basis  upon  which  an  attempt  may  be  made  to  classify  the  vari- 
ous forms  of  mental  disorder  we  shall  first  point  out  certain 
errors  to  be  guarded  against.  For  unless  a  considerable  degree 
of  caution  is  exercised  there  is  danger  lest  we  not  only  fail  in 
the  attempt  to  delineate  the  chief  characteristics  of  the  various 
symptom-complexes  in  a  manner  that  will  be  useful  in  stimu- 
lating further  study,  but  also  tend  to  foster  the  spirit  of  de- 
preciation and  pessimism  which  renders  real  progress  impos- 
sible. 

In  the  introductory  chapter  attention  was  called  to  the  fact 

1  Paton,  S. :  The  Classification  of  Mental  Diseases.  Reference  Hand- 
book of  the  Medical  Sciences.  William  Wood  &  Co.,  New  York,  1902,  vol. 
v,  p.  25.  Nissl,  F. :  Kritische  Bemerkungen  zu  Ziehen's  Aufsatz ;  Ueber 
einige  Liicken  u.  Schwerigkeiten  d.  Gruppierung  des  Geisteskrankheiten. 
Centralbl.  f.  Nervenheilk.  u.  Psych.,  1904,  Marz  15. 

15  225 


226  PSYCHIATRY 

that  the  purely  symptomalogic  study  of  the  cases,  however  ad- 
mirable it  may  be  in  certain  respects,  can  never  supply  a  suffi- 
cient basis  upon  which  to  attempt  a  grouping  of  the  various 
forms  of  alienation.  Such  a  method  of  investigation  assumes 
as  a  necessary  postulate  that  the  observation  of  symptoms  is  the 
only  important  factor  in  a  study  of  clinical  psychiatry.  More- 
over, it  was  pointed  out  that,  so  little  being  known  with  regard 
to  the  anatomy  and  physiology  of  the  brain,  any  endeavor  to 
form  a  pathological  basis  upon  which  the  cases  of  alienation 
may  be  grouped  would  be  equally  futile.  In  this  connection 
should  be  mentioned  the  attempt  that  has  been  made  by  Wer- 
nicke to  differentiate  the  several  disease  pictures  according  to 
the  supposed  localization  of  the  anatomical  processes  in  the  cen- 
tral nervous  system.  The  fundamental  assumption,  however, 
on  which  this  opinion  rests — that  a  similar  disease  process  un- 
derlies all  forms  of  mental  disturbances  in  which  there  are  ana- 
tomical lesions — amounts  to  no  more  than  a  pure  hypothesis. 
Such  a  view  does  not  take  into  account,  for  example,  the  de- 
monstrable differences,  pathological  as  well  as  clinical,  that  exist 
between  syphilitic  lesions  in  the  central  nervous  system  and  the 
changes  observed  in  dementia  paralytica,  nor  between  the  latter 
and  those  belonging  to  various  forms  of  the  senile  psychoses 
In  these  instances  we  have  to  deal  with  essentially  different 
disease  processes.  Unfortunately,  however,  as  yet  the  alienist 
has  been  able  to  recognize  only  a  few  lesions  that  have  certain 
distinctive  characteristics,  so  that  the  pathological  findings 
alone  cannot  supply  a  basis  for  classification.  Until  it  is  de- 
monstrable beyond  peradventure  that  certain  factors  in  the 
study  of  cases  of  alienation  are  of  specific  importance,  the  only 
rational  and  comprehensive  method  to  be  adopted  is  that  which 
takes  into  consideration  all  the  possible  facts  bearing  upon  the 
case;  for  the  present  at  least,  therefore,  this  must  be  regarded 
as  the  most  natural  and  the  simplest  method  of  grouping  the 
various  complexes.  Take,  for  example,  the  study  of  dementia 
paralytica.  Here  we  have  a  variety  of  clinical  symptoms  which 
in  their  totality  have  come  to  be  regarded  as  more  or  less  spe- 
cific and  are  associated  with  a  process  running  a  fairly  definite 


GROUPING    OF   MENTAL    DISEASES  227 

course,  passing  into  a  peculiarly  characteristic  dementia  and 
ending  sooner  or  later  in  death.  On  the  pathological  side  these 
clinical  changes  may  generally  be  correlated  with  certain  ana- 
tomical lesions.  When  all  these  factors  are  taken  into  account, 
we  are  able  to  recognize  a  disease  group  with  certain  definite 
clinical  characteristics  more  or  less  intimately  dependent  upon 
certain  changes  in  the  central  nervous  system. 

Such  a  method  of  grouping  as  that  which  has  been  indi- 
cated can  hardly  be  antagonistic  to  progress,  and  is  useful  in 
aiding  the  alienist  to  formulate  his  views  and  to  bring  into 
greater  prominence  many  of  the  problems  which  need  solution. 
The  first  group  of  disorders  which  will  be  discussed  are  those 
classed  as  the  defect  psychoses — idiocy,  imbecility,  and  other  de- 
grees of  mental  debility.  The  ill-defined  character  of  this  group 
and  the  empiricism  which  associates  under  the  same  head  such 
a  variety  of  disorders  will  at  once  be  recognized.  Although  the 
severer  cases  are  always  associated  with  marked  structural 
changes  of  the  nervous  system,  it  has  been  customary  to  dis- 
cuss these  disorders  not  with  those  due  to  organic  brain  disease, 
but  to  look  upon  them  as  forming  a  group  by  themselves. 

The  second  group  of  mental  disorders  which  are  consid- 
ered are  designated  acute  and  subacute,  confusional  and  deliri- 
ous states,  in  part  the  result  of  autointoxication.  These  include 
the  febrile  deliria,  the  acute  collapse  delirium,  the  so-called 
amentia  (Meynert),  and  Korsakow's  syndrome.  Although  the 
evidence  which  favors  the  autointoxication  theory  is  meagre 
and  more  or  less  indefinite,  the  possible  influence  in  these  cases  of 
toxic  products  has  not  been  lost  sight  of,  and  this  grouping 
therefore,  seems  to  be  one  which  offers  a  reasonable  working 
hypothesis.  The  next  chapter  deals  with  certain  forms  oi 
chronic  intoxication  caused  by  various  poisons — alcohol,  mor- 
phin,  cocain,  lead,  etc. 

Following  this  are  the  groups  of  manic-depressive  insanity 
and  dementia  prsecox,  in  which  the  grouping  is  based  merely 
on  the  symptomatology,  course,  prognosis,  and  termination, 
without  regard  to  the  pathological  findings,  which  are  too  in- 
definite to  be  considered  of  any  present  value. 


228  PSYCHIATRY 

Then  follows  the  large  group  of  cases  of  dementia  par- 
alytica in  which  the  same  factors  are  taken  into  account,  but 
here,  inasmuch  as  the  changes  in  the  central  nervous  system  are 
of  more  or  less  specific  importance,  they  are  given  their  due 
valuation.  The  senile  psychoses,  including  states  of  depression 
and  excitement,  mixed  states  and  dementia,  are  next  consid- 
ered. 

Under  the  head  of  epilepsy  and  hysteria  a  variety  of  symp- 
tom-complexes are  discussed  which  in  the  main  possess  certain 
distinctive  characteristics,  but  frequently  show  so  many  simi- 
larities that  it  is  impossible  to  differentiate  the  two  conditions. 
In  the  chapter  dealing  with  neurasthenia  and  the  psychasthenic 
states  we  have  attempted  merely  to  sketch  out,  as  it  were,  the 
outlines  of  a  group  which  as  yet  can  not  be  definitely  filled  in. 
Here  the  term  neurasthenia  is  reserved  for  the  pure  cases  of 
chronic  nervous  exhaustion,  while  the  term  psychasthenia  is 
applied  to  the  conditions  variously  designated  as  the  "  fear"  or 
"  anxiety"  psychoses  and  impulsive  insanity,  in  which,  in  addi- 
tion to  the  ordinary  symptoms  of  nervous  fatigue,  abnormal 
impulses,  phobias,  and  various  other  psychical  disturbances 
form  part  of  the  clinical  picture. 

A  separate  chapter  has  been  devoted  to  the  consideration 
of  the  various  forms  of  mental  disorder  associated  with  organic 
brain  lesions,  while  under  the  head  of  the  paranoia  group  are 
brought  together  certain  chronic  conditions  which  cannot  be  as 
yet  definitely  assigned  to  any  of  the  symptom-complexes  de- 
scribed. 

In  view  of  what  has  already  been  said,  the  possibility  of  the 
occurrence  of  combined  psychoses  may  readily  be  inferred.  If, 
however,  the  subject  of  insanity  is  discussed  purely  from  a 
symptomalogic  stand-point  it  would  be  impossible  to  speak  of 
combined  psychoses,  as  such  a  conception  does  not  take  into 
account  the  origin,  course,  or  termination  of  any  of  the  symp- 
tom-complexes nor  recognize  fundamental  differences  in  the 
various  clinical  pictures.  Even  to  the  casual  observer,  however, 
it  at  once  becomes  apparent  that  in  adopting  a  clinical  grouping 
of  disease  there  is  no  valid  reason  why  a  patient  may  not  pre- 
sent symptoms  which  point  to  the  possible  association  of  more 


GROUPING    OF    MENTAL    DISEASES  229 

than  one  disease  process.  There  is  plenty  of  evidence  to  show 
that  hysterical  symptoms  not  infrequently  complicate  a  number 
of  other  psychoses  :  for  example,  manic-depressive  insanity,  de- 
mentia prsecox,  general  paresis.  Apparently  v.  Krafft-Ebing 
was  the  first  to  use  the  term  "  combined  psychoses,"  but  as 
Gaupp  2  has  pointed  out,  a  distinction  must  be  made  between 
the  combined  and  the  composite  (zusammengesetzte)  psycho- 
ses. The  latter,  according  to  Ziehen  and  Wernicke,  are  to  be 
regarded  as  composite  conditions  entirely  void  of  fundamental 
distinctive  traits.  Among  the  more  important  of  the  combined 
forms  is  the  reported  association  of  manic-depressive  insanity 
with  dementia  paralytica.  Whether  or  not  the  former  may  also 
complicate  dementia  prsecox  cannot  be  decided  positively,  as 
our  knowledge  of  both  disorders  is  largely  casuistical.  The 
same  is  true  in  regard  to  the  possible  association  of  true  manic 
excitement  with  various  confusional  states.  Here  the  difficulty 
of  diagnosis  is  very  great.  There  can  be  little  doubt,  however, 
that  such  a  process  as  dementia  prsecox  not  infrequently  com- 
plicates the  defect  psychoses,  idiocy  and  imbecility,  and  to  ob- 
servations of  this  association  may  be  traced  the  belief  enter- 
tained by  some  clinicians  that  the  dementing  process  is  closely 
related  to  certain  forms  of  idiocy.  The  occurrence  of  hysterical 
symptoms  during  the  course  of  alienation  following  syphilitic 
infection  is  not  infrequent,  and  some  cases  are  on  record  in 
which  it  is  more  than  probable  that  the  ordinary  course  of  de- 
mentia prsecox  has  been  markedly  changed  by  a  complicating 
specific  infection.  The  fact  that  many  of  the  different  forms  of 
alienation  do  not  correspond  with  the  typical  pictures  may  in  a 
measure  be  accounted  for  not  only  by  the  difference  in  individ- 
ual reaction,  but  also  by  the  possible  addition  of  one  mental  dis- 
ease to  another.  V.  Krafft-Ebing  and  others  have  called  atten- 
tion to  the  development  of  dementia  paralytica  during  the 
course  of  paranoia.  The  senile  psychoses  and  the  associated 
changes  in  the  central  nervous  system  not  improbably  compli- 
cate many  other  forms  of  alienation. 

2  Gaupp,   R. :    Zur  Frage  der  kombinierten   Psychosen.      Centralbl.    f. 
Nervenheilk.  u.  Psych.,  1903,  15  December,  xxvi.  Jahrg.,  Nr.  167,  S.  766. 


CHAPTER       IX 

MENTAL     ANOMALIES     THE     RESULT     OF    DEFECTIVE     DEVELOP- 
MENT  OF   THE   CENTRAL   NERVOUS   SYSTEM  * 

Idiocy,  imbecility,  and  mental  debility  represent  the  three 
different  grades  into  which  these  disorders  may  be  divided. 
This  classification,  however,  is  purely  empirical.  The  causes 
are  either  congenital  or  acquired,  and  are  as  widely  diversified 
in  character  as  in  degree  of  intensity.  In  cases  of  the  first  cate- 
gory macroscopic  as  well  as  microscopic  lesions  are  demonstra- 
ble in  the  central  nervous  system,  while  for  the  second  and 
third  group,  on  account  of  our  limited  and  imperfect  knowl- 
edge, there  is  nothing  in  the  pathology  that  is  tangible. 

Idiocy. — From  a  purely  practical  stand-point  cases  of 
idiocy  may  be  divided  into  three  groups,  (a)  To  the  first  be- 
long the  cases  in  which  the  defect  in  the  central  nervous  system 
is  so  great  that  after  birth  the  child  lives  only  for  a  short  period 
of  time  and  its  existence  is  a  purely  vegetative  one.  The  study 
of  such  cases  furnishes  a  field  of  fruitful  exploration  for  the 
physiologist,  and  an  important  chapter  yet  remains  to  be  writ- 
ten by  any  one  who  has  the  opportunity  and  inclination  to  make 
a  careful  analysis  of  the  functionings  of  the  central  nervous 
system  of  which  such  monsters  are  capable  and  of  correlating 
the  physiological  responses  with  the  structural  conditions.2  Al- 
ready there  are  a  considerable  number  of  observations  on  record 
which  tend  to  show  that  life  may  persist  for  a  considerable 
period  of' time  even  when  all  the  higher  brain-centres  are  lack- 


1  Ireland,  W.  W. :  The  Mental  Affections  of  Children ;  Idiocy,  Im- 
becility, and  Insanity.  Phila.,  2d  ed.,  1900.  Bailey,  Pearce :  Reference 
Hand-book  of  the  Medical  Sciences,  vol.  v,  p.  145,  1902.  Starr,  M.  Allen: 
The  Cerebral  Atrophies  of  Childhood.  Organic  Nervous  Diseases.  New 
York,  1904. 

2Vaschide:     Essai   sur   la   psycho-physiologie   des   monstres   humains. 
Paris,  1903. 
230 


IDIOCY  231 

ing.  For  example,  anencephalic  monsters  not  possessing  a  cere- 
brum or  basal  ganglia  have  been  known  to  survive  for  more 
than  a  week.3  Spontaneous  or  mimetic  movements  in  such  cases 
did  not  occur,  although  external  stimulation  was  followed  in 
one  instance  by  a  bizarre  and  indescribable  reaction  of  the  facial 
muscles.  Cases  in  which  one  cerebral  hemisphere  or  the  cere- 
bellum and  corpus  callosum  have  been  entirely  absent,  and  in 
which  life  has  persisted  for  some  time,  have  been  reported. 

(b)  Of  more  immediate  interest  to  the  alienist  are  those 
cases  in  which  the  defects  in  the  central  nervous  system  are  less 
extensive.  To  this  second  class  belong  idiots  in  whom  there  is 
almost  a  complete  inability  to  utter  articulate  sounds,  but  who 
manifest  greater  complexity  and  more  coordination  of  move- 
ments than  is  found  in  those  of  the  first  group,  and,  moreover, 
give  evidence  that  they  possess  sensation  and  some  associative 
memory.  Such  individuals,  however,  practically  never  show  a 
functional  development  of  the  central  nervous  system  higher 
than  that  seen  in  infants  at  the  end  of  the  first  year  of  life.  As 
a  rule,  the  diagnosis  of  such  conditions  can  be  made  soon  after 
birth.  The  first  evidence  may  be  that  an  infant  shows  no  desire 
to  take  the  breast ;  or  about  the  time  when  in  the  normal  infant 
there  is  some  evidence  of  reaction  to  a  bright  light  (from  the 
first  to  the  third  day)  no  effect  is  produced  by  the  incident 
stimulus.  The  degree  of  impressionability  to  sensory  stimula- 
tion attained  by  such  individuals  varies  within  considerable 
latitudes. 

The  especial  symptomatology  of  individual  cases  deserves 
further  careful  and  painstaking  study.4  As  a  rule,  it  can  be 
decided  that  the  disturbances  in  sensation  are  complex  and  not 
dependent  upon  mere  interference  with  function  in  the  peri- 
pheral tract.  Although  in  some  instances  the  latter  exists,  its 
presence  cannot  be  made  to  explain  all  the  sensory  disturbances, 
since  it  is  obvious  that  there  is  also  a  considerable  defect  in  the 
reception,  elaboration,  and  retention  of  sensory  impressions.  As 

3  Anton,  G. :    Anencephalie  und  Hemicephalie.     Handbuch  der   Path, 
des  Nervensystems.     Berlin,  1904. 

*Sollier:     Psychologie  de  l'idiot  et  de  l'imbecile.     Paris,  1891. 


232 


PSYCHIATRY 


would  be  expected,  all  forms  of  associative  memory  seem  to  be 
affected,  and  taste,  smell,  touch,  sight,  and  hearing  are  more  or 
less  seriously  disturbed.  Sometimes  mentally  defective  infants 
seem  to  lack  the  most  elementary  organic  sensations  and  are 
deficient  in  even  the  purely  animal  instincts.  Although  they 
may  react  to  both  visual  and  auditory  stimuli,  the  reaction  has 
no  meaning  for  them ;  they  fail  to  recognize  their  parents,  and 
never  appear  to  become  familiar  with  the  objects  with  which 
they  are  almost  continually  brought  into  contact.  Their  capac- 
ity for  attention  is  at  a  very  low  ebb.  Bright  objects  held  be- 
fore the  infant  fail  to  attract  its  gaze,  and  even  if  the  eyes  are 
turned  in  the  direction  of  the  stimulus,  one  observes  only  a 
vacant  stare  without  any  objective  evidence  of  association  be- 
tween the  sensory  impressionability  and  the  visible  reaction. 
The  associative  processes  are  very  limited.  Even  the  most  ele- 
mentary— those  necessary  for  the  development  of  orientation — 
are  deficient,  and  such  creatures  often  seem  to  be  unable  to 
appreciate  the  direction  of  sounds,  rolling  their  heads  about 
vaguely  and  seldom  turning  their  eyes  in  the  direction  from 
which  these  have  emanated.  Even  the  elementary  emotional 
reactions — smiling  or  other  expressions  of  pleasure — may  be 
completely  absent.  In  some  instances  the  power  of  movement 
becomes  more  extensive  and  incoordination  does  not  develop. 
In  other  cases  the  ataxia  becomes  less  marked,  but  the  move- 
ments are  clumsy  and  at  times  almost  choreiform  in  character. 

(c)  The  third  group  of  cases  consists  of  those  which  up 
to  the  present  time  have  received  the  most  careful  study  and  are 
characterized  by  a  limited  power  of  speech,  comprehension,  and 
articulation.5  In  some  instances  the  attempts  at  articulation 
are  restricted  to  a  few  guttural  sounds  more  suggestive  of  the 
grunting  of  an  animal  than  of  human  speech.  But  even  in  cases 
where  neither  spontaneous  speech  nor  the  comprehension  of 

5  Emminghaus  :  Die  psychischen  Storungen  des  Kindesalters.  Tubin- 
gen, 1887.  Sollier :  Op.  cit.  Voisin,  J. :  LTdiotie.  Paris,  1893.  Ham- 
marberg:  Studien  iiber  Klinik  und  Pathologie  der  Idiotie.  Deutsch  von 
Berger,  1895.  Storring,  Gustav:  Vorlesungen  iiber  Psychopathologie  in 
ihrer  Bedeutung  fur  die  normale  Psychologic     Leipzig,  1900. 


IDIOCY  233 

spoken  language  is  developed,  one  must  be  careful  to  look  for 
the  existence  of  other  forms  of  association,  since  not  infre- 
quently these  may  have  reached  a  relatively  much  greater  devel- 
opment, which  can  be  detected  by  observing  the  movements,  the 
power  of  expression,  and  the  apprehension  of  visual  stimuli, 
such  as  the  recognition  of  cards,  pictures,  and  so  on. 

In  another  group  of  cases,  although  articulation  is  re- 
stricted to  a  few  words  or  syllables,  the  comprehension  of  signs 
or  spoken  words  may  attain  a  still  higher  development,  so  that 
the  characteristics  of  simple  objects,  the  nature  of  the  environ- 
ment, and  familiar  faces  are  recognized  better  than  one  would 
at  first  be  led  to  suspect.  In  such  cases  there  may  be  a  marked 
appreciation  of  physical  qualities, — the  difference  between  heat 
and  cold, — of  a  sense  of  comfort  or  discomfort,  and  even  a  com- 
prehension of  the  nature  and  uses  of  a  variety  of  ordinary  ob- 
jects. In  still  another  class  of  cases  speech  comprehension  and 
articulation  have  advanced  still  further.  Associative  memory  is 
much  better  developed  and  the  patients  are  able  to  pick  out  dif- 
ferent letters  or  cards ;  they  acquire  a  wider  vocabulary  and  can 
associate  names  with  objects.  The  organic  sensations  seem  to  be 
more  complex,  the  associative  qualities  concerned  in  taste  and 
smell  are  more  highly  developed.  Elementary  feelings  of  pleas- 
ure, discomfort,  or  pain  are  associated  with  certain  persons,  ob- 
jects, or  phenomena.  These  patients  differentiate  to  some  ex- 
tent between  those  who  are  kind  to  them  and  those  who  are  not 
friendly.  The  dissociation  between  emotional  reaction  and  idea- 
tion is  less  marked.  A  slight  appreciation  of  time  may  develop 
and  an  evident  familiarity  with  the  environment  is  often  a 
prominent  feature.  As  a  rule,  these  patients  need  to  be  care- 
fully watched.  They  may  be  subject  to  impulsive  acts  or  sud- 
den outbursts  of  temper.  The  simple  organic  sensations 
predominate,  and  whatever  interest  develops  is  usually  that 
associated  purely  with  the  personal  needs. 

Certain  observers  have  divided  their  cases  into  two  groups 
— the  anergetic  or  apathetic  form  and  the  erethic  or  versatile 
type.  In  the  former  the  power  of  directing  the  attention  is  in 
some  cases  almost  absent,  and  all  forms  of  emotional  reactions 


234 


PSYCHIATRY 


are  deficient  or  merely  embryonic  in  character.  In  patients  of 
the  latter  group  it  is  possible  to  attract  the  attention  and  affect- 
ive reactions  often  follow.  To  this  category  belong  the  indi- 
viduals who  are  capable  of  being  trained  up  to  a  certain  point, 
and  can  be  taught  to  some  extent  to  administer  to  their  own 
wants,  to  feed,  dress,  and  wash  themselves  and  perform  other 
light  duties. 

The  power  of  attention  may  be  variously  estimated  by  test- 
ing the  power  to  remember  cards,  pictures,  colors,  and  the  more 
simple  characteristics  of  objects  and  persons.  As  Storring  has 
pointed  out,  the  speech  development  is  not  proportional  to  the 
amount  of  mentality.  Some  idiots  show  a  considerable  ability 
to  express  themselves  audibly  and  name  familiar  objects  cor- 
rectly, and  yet  at  the  same  time  possess  an  intellectual  capacity 
much  below  that  of  others  whose  speech  is  far  less  developed. 
Certain  of  these  individuals  even  attain  to  the  mental  status  of 
the  ordinary  child  between  the  ages  of  six  and  eight  years — 
about  the  time  it  begins  to  go  to  school. 

The  physical  manifestations  in  idiocy  are  varied  and  nu- 
merous. Those  which  pertain  to  the  skull  and  nervous  system 
will  be  described  when  we  come  to  speak  of  the  pathology.  The 
disproportionateness  in  the  development  of  the  head,  extremi- 
ties and  trunk  is  often  well  marked.  The  teeth  are  nearly  al- 
ways irregular.  Not  infrequently  the  sensory  organs  show  gross 
anatomical  defects.  It  has  been  estimated  that  from  6  to  8 
per  cent,  of  these  unfortunates  are  either  born  blind  or  become 
so  early  in  life,  while  in  other  cases  the  peripheral  visual  tract 
is  intact.  Paralyses  of  the  ocular  muscles  are  common.  Hear- 
ing is  sometimes  defective,  but  this  is  not  so  frequent  an  occur- 
rence as  the  impairment  of  sight.  Disturbances  in  taste  and 
smell,  other  than  those  of  psychical  origin,  are  rare.  The 
organic  sensibility  is  depressed,  and  these  defects  may  give  rise 
to  various  complications.  Thus,  some  idiots  never  experience  a 
sense  of  satiety  and  will  keep  on  eating  or  drinking  until  com- 
pelled to  stop.  Owing  to  the  feebleness  in  somatic  sensation, 
the  patient  may  not  know  when  to  defecate  or  urinate,  so  that 
incontinence  or  retention  may  result.    The  great  variety  of  de- 


IMBECILITY  235 

fects  of  the  bony  system,  among  the  most  common  of  which  is 
caries,  need  not  be  described  in  detail  here.  Idiots  are  particu- 
larly susceptible  to  pulmonary  disorders,  especially  tubercu- 
losis. Again,  the  lack  of  cleanliness  may  give  rise  to  various 
complications. 

The  sexual  organs,  as  a  rule,  show  marked  defects.  Unde- 
scended or  poorly  developed  testes,  hypospadias,  and  phimosis 
are  some  of  the  most  common  abnormalities.  The  sexual  func- 
tions are  either  absent  or  perverted. 

The  motor  disturbances  are  usually  well  marked,  and  the 
limbs  may  be  small.  In  some  cases,  particularly  in  the  acquired 
forms  due  to  the  cerebral  palsies,  paralyses  exist — paraplegias, 
monoplegias,  and  diplegias.  Atrophies  may  be  present.  The 
reflexes  are  sometimes  exaggerated,  in  other  cases  deficient  or 
absent.  Anomalies  in  the  salivary  secretions,  digestive  disturb- 
ances, regurgitation,  nausea,  and  vomiting  are  not  uncommon. 

Semi-Idiocy,  or  Imbecility. — In  the  semi-idiot,  or  imbecile, 
all  forms  of  associative  memory  reach  a  higher  complexity  than 
in  the  idiot.  Sense  memories,  above  all  those  associated  with 
vision  and  less  commonly  those  concerned  with  hearing,  show 
much  more  stability,  and  the  patient  possesses  much  greater 
facility  in  re-collecting  and  redeveloping  them ;  so  that  as  a  rule 
imbeciles  become  familiar  with  a  great  variety  of  objects,  par- 
ticularly those  with  which  they  are  most  frequently  brought 
into  contact.  Again,  such  individuals  have  the  power  of  appre- 
hending and  appreciating  to  some  extent  the  quality  of  objects. 
They  are  capable  of  differentiating  between  the  simpler  colors, 
are  able  to  remember  names,  particularly  those  of  members  of 
their  own  family,  although  they  are  usually  unable  to  appreciate 
the  finer  differences  involved  in  comparison  and  contrasts. 
Their  vocabulary  is  generally  limited  to  naming  objects,  and 
frequently  the  interrogative  is  simply  expressed  by  giving  utter- 
ance to  the  name  of  the  object  concerning  which  their  curiosity 
is  aroused.  Adjectives  are  used  more  frequently  than  adverbs 
and  prepositions,  and  the  more  complicated  associations  are  apt 
to  be  feeble  or  entirely  deficient.  These  deficiencies  in  the  asso- 
ciative memory  are  largely  dependent  upon  lapses  in  the  atten- 


236  PSYCHIATRY 

tion.  Imbeciles  never  possess  the  power  of  making  any  pro- 
longed mental  effort  or  of  keeping  any  object  for  more  than  a 
few  seconds  within  the  focus  of  the  attention. 

The  emotional  displays  of  the  imbecile,  although  not  as 
crude  nor  characterized  by  the  dissociation  that  is  so  marked  in 
those  of  the  real  idiot,  are  still  incomplete,  monotonous,  and 
largely  confined  to  the  expression  of  pleasure  or  pain.  These 
individuals  are  practically  never  able  to  appreciate  anything 
which  does  not  immediately  concern  their  own  interests.  The 
power  of  differentiating  between  right  and  wrong  is  purely  ele- 
mentary, and  none  of  the  affective  states  shows  any"  altruistic 
tendencies.  The  acts  are  largely  the  result  of  transitory  im- 
pulses, and  a  volitional  movement,  the  result  of  deliberate  choice 
and  judgment,  is  scarcely  ever  witnessed.  At  times  the  impulses 
and  motives  are  replaced  by  attempts  to  copy,  and  this  power 
of  imitation  is  the  one  important  clue  to  the  future  training  of 
the  patient.  Imbeciles  are  particularly  prone  to  be  the  subject 
of  sexual  impulses;  these  defectives  are  very  apt  to  wander 
away  from  home  and  thus  form  a  very  considerable  percentage 
of  the  vagabonds  and  unemployed  poor.  Their  excessive  emo- 
tional outbreaks  not  infrequently  lead  them  to  resort  to  vindic- 
tive and  brutal  acts.  Hatred  in  the  true  meaning  of  the  word, 
however,  cannot  be  said  to  exist  in  their  minds,  inasmuch  as 
their  actions  are  dictated  by  impulse.  Nevertheless,  under  the 
spur  of  a  sudden  provocation  they  sometimes  attempt  to  damage 
property,  set  fire  to  houses,  or  attack  members  of  the  family  of 
those  who  have  irritated  them. 

Again,  the  movements  of  the  imbecile  are  far  more  pur- 
poseful and  coordinated  than  those  of  the  idiot,  and  the  physi- 
cal symptoms  are  much  less  pronounced.  Speech  comprehen- 
sion and  articulation  are  far  better  developed,  although  more  or 
less  defect  is  generally  present — lisping,  stammering,  and  the 
like.  Sometimes  these  patients  have  difficulty  in  the  pronuncia- 
tion of  certain  consonants — G  and  ;K,  G  and  T,  S,  R,  or  L.  At 
times  all  the  movements  concerned  in  the  articulation  of  speech 
seem  to  be  hampered.  The  movements  of  the  tongue  are  more 
or  less  limited.     The  disturbances  of  speech  in  mentally  im- 


MENTAL   DEBILITY  237 

paired  children  have  been  carefully  studied  by  Liebmann,6  who 
divides  them  according  to  their  etiology  as  follows  :  ( 1 )  The 
so-called  secondary  troubles,  including  mutism  and  agramma- 
tism, stuttering,  and  lisping.  (2)  Primary  troubles  in  which 
the  speech,  though  present,  is  indistinct.  The  latter  are  depend- 
ent either  upon  organic  or  functional  causes.  Among  the  causes 
of  the  former  are  malformations  or  paralyses  of  the  palate,  nar- 
rowing of  the  pharynx  caused  by  local  obstructions,  and  dis- 
turbances of  hearing. 

The  movements  of  the  tongue  are  always  somewhat  lim- 
ited. The  other  motor  defects  are  generally  more  obvious  in 
connection  with  the  finer  and  more  coordinated  forms,  such  as 
those  necessary  in  grasping  a  pen  or  holding  a  fork.  The  man- 
ners and  gait  of  such  individuals  may  be  coarse  and  clownish, 
and  immediately  suggest  the  decided  mental  impairment  that 
exists. 

Mental  Debility  or  Enfeeblement. — Under  this  category 
belong  a  large  group  of  individuals  who  never  attain  the  mental 
development  of  the  average  normal  adult.  All  forms  of  grada- 
tion and  transition  exist  between  this  and  the  preceding  group, 
and  no  sharp  line  of  demarcation  can  be  drawn.  As  a  rule, 
such  individuals  show  no  deficiency  in  the  mere  reception  and 
retention  of  sensory  impressions.  Indeed,  certain  forms  of 
memory  may  be  developed  even  abnormally.7  This  is  particu- 
larly true  in  regard  to  figures,  and  individuals  are  occasionally 
met  with  who  in  many  ways  show  a  deficient  mentality,  but 
have  the  most  remarkable  power  of  calculating  and  of  remem- 
bering figures.  Many  of  the  arithmetical  or  calculating  "  won- 
ders" belong  to  this  class.  As  a  rule,  the  memories  which  relate 
to  the  individual's  home,  the  names  of  the  various  members  of 

8  Die  Sprachstorungen  geistig  zuruckgebliebener  Kinder.  Samml.  von 
Abhandl.  a.  d.  Gebiete  der  pad.  Psych.,  iv,  3.  Berlin,  1901.  Stotternde 
Kinder.  Ibid.,  1903.  Liebmann  u.  Edel.  Die  Sprache  der  Geisteskranken. 
Halle  a/S.,  Marhold,  1903. 

7  Peterson,  F. :  Idiot  Savants.  Popular  Science  Monthly,  New  York, 
December,  1896.  Wizel,  Adam:  Ein  Fall  von  phanomenalem  Rechnen- 
talent  bei  einem  Imbecillen.  Arch.  f.  Psych,  u.  Nervenkrankh.,  1904,  Bd. 
xxxviii,  H.  1,  S.  122. 


238  PSYCHIATRY 

his  family,  of  his  immediate  friends,  and  all  those  with  whom 
he  is  brought  into  daily  contact  are  well  preserved.  Deficien- 
cies only  become  apparent  when  the  associative  forms  of  mem- 
ory necessary  for  the  re-collecting  of  abstract  ideas  are  carefully 
studied.  The  imagination  in  such  individuals  is  apt  to  be  well 
developed,  so  that  not  infrequently  the  actual  defects  in  the 
higher  forms  of  memory  are  concealed  by  the  vivid  play  of  their 
fantasy,  which  in  many  instances  resembles  that  seen  in  cases  of 
hysteria.  As  has  been  said,  the  simpler  forms  of  associative 
memory,  particularly  those  connected  with  the  senses,  show 
comparatively  few  defects,  but  the  mental  impairment  that  ex- 
ists is  frequently  brought  out  by  an  attempt  on  the  part  of  the 
individual  to  concentrate  his  attention  for  a  certain  length  of 
time.  Furthermore,  the  judgment  of  such  individuals,  except 
concerning  the  simplest  things  and  the  most  ordinary  events  of 
life,  shows  considerable  deficiency.  Not  uncommonly  these 
deficiencies  are  first  noticeable  at  the  time  when  the  child  first 
goes  to  school.  An  attempt  at  manual  training  brings  these  out 
far  less  than  the  study  of  books.  The  emotional  life,  although 
at  first  normal,  is  apt  to  show  anomalies,  particularly  in  regard 
to  the  feelings  connected  with  the  aesthetic  and  ethical  senses. 
The  egotism  of  these  individuals  is  usually  striking  and  may  be 
the  most  dominating  feature  in  the  symptomatology.  As  they 
are  brought  more  into  contact  with  the  world  they  begin  to 
exhibit  eccentricities  of  character. 

In  the  apathetic  type  the  symptoms  are  those  of  indiffer- 
ence, frequently  mistaken  for  pure  laziness,  the  absence  of  any 
high  aim  or  ideals,  the  desire  to  lead  a  life  as  uninterrupted  and 
placid  as  possible  without  regard  for  the  welfare  of  those  about 
them.  In  the  earlier  years  of  childhood  these  anomalies  become 
apparent  in  the  disinclination  shown  to  associate  with  other 
children,  in  the  frequent  desire  expressed  to  be  left  alone.  With 
the  years  of  puberty  the  defects  may  become  more  apparent,  or, 
instead  of  the  apathy,  fluctuations  in  the  emotional  life  may  be- 
come more  and  more  marked.  Such  children  show  a  marked 
tendency  to  lie  and  steal  and  are  very  likely  to  become  a  care 
and   burden   to    their    family.      Later,    sexual    and    alcoholic 


MORAL    INSANITY  239 

excesses  become  more  and  more  common  and  are  lacking  only 
in  a  very  few  of  these  individuals. 

Moral  Insanity. — The  very  mildest  cases  of  mental  impair- 
ment are  frequently  to  be  found  among  the  large  group  of  cases 
commonly  referred  to  as  instances  of  moral  insanity.  In  these 
forms  the  defects  are  largely  in  the  ethical  spheres  and  are  the 
result  of  impulses,  lack  of  inhibition,  and  a  variety  of  other 
causes  which  are  often  very  difficult  to  recognize.  Many  of 
these  cases,  developing  as  they  do  in  individuals  who  show  a 
marked  hereditary  predisposition,  may  be  easily  confused  with 
the  various  psychopathic  states.  At  times  they  are  complicated 
with  hysterical  symptoms  and  in  other  patients  they  are  asso- 
ciated with  epileptiform  attacks.  The  imperative  processes  are 
often  noted  in  idiocy  as  well  as  in  imbecility. 

The  early  recognition  of  these  cases,  as  has  already  been 
pointed  out,  is  of  great  importance,  inasmuch  as  the  existence  of 
mental  defects  in  children  should  call  for  their  removal  from  the 
public  schools  and  their  relegation  to  institutions  especially 
adapted  to  their  peculiar  needs.  Recently  Consoni 8  has  called 
attention  to  the  importance  of  careful  study  of  the  anomalies  of 
attention  that  occur  in  feeble-minded  children  as  one  of  the  best 
means  for  the  early  recognition  of  the  existing  defect.  In 
psychasthenic  children  a  certain  degree  of  static  conative  atten- 
tion is  always  present.  Furthermore,  the  degree  of  the  general 
capacity  for  attention  is  in  direct  proportion  to  the  affective 
state  and  their  power  of  inhibition.  In  normal  children  the 
capacity  for  the  conative  dynamic  attention  is  more  developed, 
and  is  an  indication  of  the  activity  of  the  cerebral  processes. 

Etiology. — The  estimation  of  the  number  of  imbeciles  in 
the  community  with  any  degree  of  accuracy  is  practically  impos- 
sible, as  a  large  number,  particularly  those  in  the  lower  classes 
of  society,  never  come  under  medical  supervision.  On  account 
of  the  impaired  physical  state  of  this  class  of  individuals  the 
death-rate  is  particularly  high  in  the  earlier  years  of  life,  so  that 


8  Consoni,  F. :   La  Mesure  de  1'attention  chez  les  enfants  faibles  d'esprit 
(Phrenastheniques).      Arch,  de  Psych.,  1903,  No.  7,  t.  ii,  fasc.  3,  p.  209. 


240 


PSYCHIATRY 


for  adults  the  proportion  is  comparatively  much  less.  The 
cases,  as  a  rule,  may  be  divided  into  (i)  congenital  and  ^2) 
acquired  forms. 

( 1 )  Of  prime  importance  is  the  so-called  neuropathic  de- 
generation of  the  parents.  If  the  family  histories  are  carefully 
examined  it  will  be  found  that  probably  one  and  sometimes  both 
parents  have  been  the  subjects  of  nervous  or  mental  disorders. 
This  is  somewhat  more  commonly  observed  on  the  mother's 
than  on  the  father's  side.  The  next  most  important  factor  is 
alcohol.  According  to  the  classical  researches  of  Bourneville,9 
in  1000  cases  of  imbecility  alcoholism  in  the  father  was  noted 
471  times,  in  the  mother  84  times,  and  in  both  parents  65  times. 
Demme  found  that  the  occurrence  of  alcoholism  was  noted  in 
81.9  per  cent,  of  the  parents,  and  that  in  ten  families  of  alco- 
holics normal  children  were  noted  in  only  17.5  per  cent. 

Without  question  syphilis  in  the  parents  very  often  pro- 
duces mental  defects  in  the  children,  although  some  of  the  Eng- 
lish statistics,  particularly  those  of  Piper,  would  seem  to  indi- 
cate that  its  significance  has  been  somewhat  overestimated. 
This  point,  however,  has  not  as  yet  been  satisfactorily  settled, 
and  the  whole  subject  needs  fuller  investigation,  particularly  as 
in  many  cases,  for  various  reasons,  it  is  impossible  to  obtain 
definite  data  with  regard  to  the  presence  or  absence  of  luetic 
infection  in  the  parents.  A  remarkable  contrast  is  noticeable  be- 
tween these  figures  and  those  given  in  regard  to  the  importance 
of  tuberculosis  as  an  etiological  factor.  Here  the  proportion 
varies  from  those  of  Piper — 23  per  cent. — to  those  of  Kalin — 
56  per  cent.  But  here  again  figures  are  apt  to  be  misleading, 
and  it  should  not  be  forgotten  that  tuberculosis  is  said  to  occur 
in  15  per  cent,  of  the  parents  of  healthy  children.  Again,  it  is 
also  worthy  of  note  that  in  scrofulous  children  imbecility  does 
not  occur  more  frequently  than  in  the  non-scrofulous.  The  im- 
portance of  lead  and  various  other  toxic  substances,  as  well  as 
severe  illnesses,  protracted  fevers  and  trauma,  have  been  vari- 
ously emphasized  as  important  factors  in  the  parents  in  the  pro- 

8  Progres  med.,   1897,  No.  2.     Recherches  cliniques  et  therapeutiques 
sur  l'epilepsie,  l'hysterie  et  l'idiotie.     Paris,  1902. 


ETIOLOGY   OF   IDIOCY  241 

duction  of  idiocy  in  the  children.  The  marriage  between  blood 
relatives,  where  a  neuropathic  family  taint  exists,  undoubtedly 
emphasizes  such  a  tendency,  and  the  children  are  liable  to  be 
defective. 

Some  observers  have  taken  occasion  to  emphasize  the  fact 
that  imbecility  is  somewhat  more  common  among  the  firstborn 
than  it  is  among  second  and  third  children.  This  may  be  due 
to  the  greater  difficulty  attending  the  first  as  compared  with 
subsequent  labors. 

(2)  Among  the  more  important  of  the  causes  of  acquired 
idiocy  are  all  the  injurious  factors  which  may  affect  the  embryo 
through  the  mother.  Among  the  laity  it  is  generally  supposed 
that  severe  mental  shocks,  frights,  and  the  like  are  very  apt  to 
exert  a  detrimental  effect  upon  the  mental  as  well  as  upon  the 
physical  powers  of  the  child.  This  may  be  in  certain  cases  due 
to  disturbances  in  the  uterine  circulation,  but  in  all  probability 
the  importance  of  psychic  shock  in  this  connection  has  been  ex- 
aggerated. The  occurrence  of  nervous  diseases  during  the 
months  of  pregnancy  is  particularly  apt  to  give  rise  to  mental 
defects  in  the  child.  Premature  birth  is  also  another  cause,  but 
in  this  connection  it  must  not  be  forgotten  that  certain  of  these 
cases  are  due  to  syphilitic  infection  in  the  parent.  The  various 
kinds  of  trauma  that  may  befall  the  mother  are  also  of  great 
importance  in  the  etiology. 

In  about  one-third  of  the  cases  of  acquired  mental  impair- 
ment diseases  occurring  during  the  earliest  years  of  life  are  of 
the  greatest  etiologic  significance,  and  not  a  few  children,  born 
healthy,  after  a  severe  attack  of  diphtheria,  influenza,  measles, 
scarlet  fever,  typhoid  fever,  or  meningitis,  are  left  mentally  de- 
ficient. This  is  also  true  for  those  who  have  had  rickets,  ence- 
phalitis, hydrocephalus,  and  various  forms  of  convulsions. 
Epilepsy  by  itself  is  seldom  the  cause  of  the  defect,  but  mental 
impairment  is  frequently  associated  with  the  seizures  and  forms 
an  integral  part  of  the  same  complex. 

Koenig10  affirms  that  a  complete  chain  may  be  traced  be- 

10  Koenig,  W. :  Ueber  cerebralbedingte  Komplikationen  welche  den  cere- 
bralen  Kinderlahmungen  wie  der  einfachen  Idiotie  gemeinsam  sind,  sowie 

16 


242  PSYCHIATRY 

tween  the  cerebral  palsies  on  one  side,  in  which  there  is  a  nor- 
mal mentality,  to  the  cases  of  pronounced  idiocy  without  any 
evidence  of  impaired  motility. 

The  following  table  from  his  second  paper  represents  an 
attempt  to  compare  the  etiological  factors  in  260  cases  of  idiocy 
with  those  in  70  cases  of  cerebral  palsy : 

Cerebral  Simple 

Palsy.  Idiocy. 

1.  Mental  or  nervous  diseases  in  the  as- 

cendants     about  28.5%  32    % 

2.  Phthisis  in  the  ascendants   about  14.4%  about      13.8% 

3.  Father  markedly  alcoholic    23    %  about      15   *fo 

4.  Mental  shock  to  mother  during  preg- 

nancy    23    %      about      12.5% 

5.  Physical    trauma     to    mother    during 

pregnancy     about    2.9%      about       3    % 

6.  Relationship   between   the    father   and 

mother    1.4%  about        1.1% 

7.  First  birth 27.1  %  about      17.6% 

8.  Premature  birth    10    %  3-8% 

9.  Born  in  wedlock  10    %  6.5% 

10.  Child  always  sickly  15-7%  10    % 

11.  Child  last  of  family  or  last  of  a  num- 

ber  of  children    10    %  16.9% 

12.  Nervous    or    mental    disturbances    in 

brothers  or  sisters  7-i%  30.7% 

13.  Phthisis   or   scrofula   in   brothers   and 

sisters     5.7%  2.3% 

14.  Death  of  brothers  or  sisters   in  early 

years,   or   suspected   abortions    ....  35.7%      about      16.8% 

15.  Difficult  birth  or  asphyxia  11.4%  (14%  ?)   10    % 

16.  Trauma   5.7%                     2.6%  (2.5%  ?) 

17.  Infectious  diseases   7-1%                     3-4%  (2.3%  ?) 

18.  Lues    4    %  certainly   6.5%  surely 

3    %  probably    4.2%  probably 

Non-myxcedematons  Infantilism. — In  the  consideration  of 
these  defect  psychoses  a  brief  mention  may  be  made  of  cases  of 
infantilism  not  associated  with  disturbances  in  the  function  of 
the  thyroid  gland,  but  more  or  less  directly  dependent  upon  pul- 


iiber  die  abortiven  Formen  der  ersteren.  Ztschr.  f.  Nervenheilk.,  Bd.  xi. 
Die  Aetiologie  der  einfachen  Idiotie  verglichen  mit  derjenigen  der  cere- 
bralen  Kinderlahmungen.  Allg.  Ztschr.  f.  Psych,  u.  psych. -gericht.  Med- 
izin,  1904,  Bd.  lxi,  H.  1  and  2,  S.  133. 


NON-MYXCEDEMATOUS    INFANTILISM  243 

monary  and  cardiac  lesions  or  upon  malaria.  Andral  and  Tar- 
dieu,  as  well  as  others  among  the  older  writers,  had  directed  at- 
tention to  this  subject,  but  it  remained  for  Hirtz  to  point  out 
the  close  relationship  that  seemed  to  exist  between  certain  forms 
of  infantilism  and  tuberculosis.  In  1871  Lorain  described 
a  degenerative  infantilism  characterized  by  physical  anomalies 
and  a  persistence  of  many  of  the  youthful  qualities  during  life. 
In  this  type  it  was  noticed  that  the  afflicted  individuals  were  be- 
low the  normal  height,  did  not  have  hair  on  the  parts  of  the  body 
where  it  appears  in  the  normal  adult,  and  that  the  sexual  organs 
were  incompletely  developed.  The  intelligence  in  these  individ- 
uals, however,  was  not  greatly  impaired.  Mitral  or  pulmonary 
stenosis  was  often  present.  These  cases  are  capable  of  being 
differentiated  from  those  of  myxcedematous  infantilism.  At 
the  time  of  puberty  it  is  found  that  the  physical  and  mental 
changes  do  not  take  place.  In  girls  menstruation  is  absent,  the 
breasts  do  not  develop,  and  the  whole  appearance  of  the  indi- 
vidual retains  the  infantile  characteristics.  It  has  been  definitely 
shown  that  the  imperfect  development  is  not  due  to  the  anoma- 
lies in  the  sexual  organs,  since  in  other  cases  it  has  happened 
that  after  castration  normal  development  has  followed.  In  the 
production  of  this  form  of  infantilism  tuberculosis  and  malaria 
are  undoubtedly  factors  of  importance.  Associated  with  the 
cardiac  and  cardio-vascular  disturbances  we  not  infrequently 
find  a  delayed  and  impaired  development  of  the  whole  body 
characterized  by  smallness  of  stature,  lack  of  development  in  the 
limbs,  absence  of  hair  in  the  axilla  and  about  the  genitals,  asso- 
ciated with  a  deficiency  of  the  sexual  sense  and  a  certain  degree 
of  mental  enfeeblement.  Such  individuals  are  very  often  consid- 
ered lazy;  they  are  subject  to  emotional  anomalies  and  phobias; 
they  are  greatly  troubled  by  excessive  blushing  and  show  slight 
eccentricities  in  character.  In  the  case  examined  by  Fer- 
ranini  n  there  was  found  a  deficient  intestinal  absorption,  a 
quantitative  insufficiency  of  the  albuminous  derivatives  in  the 


11  Ueber  von   der   Schilddriise   unabhangigen   Infantilismus.     Arch.    f. 
Psych,  u.  Nervenkrankh.,  1904,  Bd.  xxxviii,  H.  1,  p.  206. 


244  PSYCHIATRY 

urine,  a  moderate  increase  in  the  elimination  of  the  alloxuric 
bases,  a  deficiency  in  the  excretion  of  uric  acid,  and  an  increase 
of  ammonia.  The  chlorides,  the  quantity  of  the  urine,  and  its 
acidity  were  subnormal. 

Pathology. — The  pathology  of  the  defect  psychoses  is  ex- 
tensive and  includes  a  variety  of  macroscopic  as  well  as  micro- 
scopic lesions,  the  result  of  the  action  of  injurious  agencies 
which  directly  inhibit  the  development  of  the  central  nervous 
system.12  In  the  severer  cases  not  only  are  defects  found  in  the 
brain,  but  accompanying  lesions  are  noted  in  other  parts  of  the 
nervous  system.  The  alienist  is  more  particularly  concerned 
with  those  cases  in  which  structural  imperfections  are  not  so 
sufficiently  extensive  as  to  preclude  the  existence  of  all  men- 
tality, so  that  to  him  the  cases  of  acephalic  or  anencephalic  mon- 
sters are  not  of  special  interest.  The  description  of  the  various 
malformations  of  the  skull  and  their  relation  to  the  brain  is  a 
subject  that  cannot  be  discussed  in  detail  in  this  book.13  Co- 
existing and  related  defects  of  the  skull  and  brain  are  sometimes 
found,  but  these  are  not  constant,  nor  is  there  always  apparent 
in  the  skull  any  external  evidence  of  the  intracranial  lesion. 

Premature  ossification  frequently  takes  place  in  cases  of 
idiocy,  but  although  a  diminution  in  the  volume  of  the  brain  is 
sometimes  associated  with  decreased  capacity  in  that  of  the 
skull,  these  two  conditions  are  not  always  coincident.  Disturb- 
ances occurring  during  intra-uterine  life — rhachitis  fcetalis, 
chondrodystrophia  fcetalis,  or  the  osteogenesis  imperfecta  of  the 
newborn — may  be  the  cause  of  curious  structural  anomalies, 
such  as  partial  or  general  craniostenosis.  There  may  be  a 
hyperplastic  condition  of  the  brain  with  a  marked  hyperostosis 
at  the  base  of  the  skull,  and  instead  of  being  premature  the  ossi- 

12  Hammarberg :  Studium  iiber  Klinik  u.  Pathol,  der  Idiotic  Upsala, 
1895.  Bourneville :  Recherches  cliniques  et  therapeutiques  sur  l'epilepsie, 
l'hysterie  et  l'idiotie,  vol.  i  et  seq.  Paris,  1900.  Spiller,  W.  G. :  A  Contri- 
bution to  the  Pathology  of  Imbecility  and  Idiocy,  Phil.  Med.  Journal, 
March  12,  1898. 

13  See  Anton :  Entwickelungsanomalien  des  Gehirns.  Handbuch  der 
patholog.  Anat.  des  Nervensystems.  Herausgegeben  v.  Flatau,  Jacobsohn 
u.  Minor,  Berlin,  1903. 


MICROGYRIA  245 

fication  of  the  cranial  bones  may  be  delayed.  This  latter  con- 
dition has  been  noted  in  cases  of  congenital  syphilis.  The 
defects  involving  actual  loss  of  the  substance  of  the  brain  are 
manifold.  Among  the  more  important  are  those  in  which  there 
is  complete  or  partial  absence  of  the  commissural  fibres,  particu- 
larly of  the  corpus  callosum  and  of  the  anterior  commissure. 
In  some  of  these  cases  there  is  a  corresponding  change  in  the 
shape  and  size  of  the  convolutions,  particularly  those  on  the 
mesial  surface  of  the  brain,  where  the  convolutions  are  irregu- 
larly developed.  In  some  instances  the  gray  matter  is  relatively 
intact,  the  greater  loss  of  substance  being  found  in  the  white 
matter.  Duret  has  called  attention  to  the  fact  that  the  compli- 
cated vascular  system  in  the  pia  does  not  develop  before  the 
fourth  fetal  month  and  that,  as  branches  from  these  vessels  pen- 
etrate the  cortical  substance,  marked  disturbances  during  the 
process  of  development  become  possible.  According  to 
Anton  14  the  anomalies  in  development  of  the  cerebral  cortex 
itself  are  frequently  noted,  and  according  to  Hammar- 
berg  three  types  of  cortical  defects  occur.  First,  there  may 
be  a  persistence  of  the  embryonal  arrangement  of  the  cellular 
elements,  both  as  regards  their  distribution  and  individual  char- 
acter, cells  as  well  as  fibres  retaining  their  primitive  type.  The 
zonal  fibres  are  few  in  number,  occasionally  only  traces  of  them 
being  found.  Second,  in  the  less  severe  cases  the  embryonal 
type  of  the  elements  is  lost,  but  their  arrangement  and  number 
correspond  to  the  development  noticed  in  children  at  the  end  of 
the  first  year.  The  third  class  represents  a  slightly  more  ad- 
vanced stage  of  development.  Sachs 15  has  called  attention  to 
similar  conditions  in  cases  of  the  so-called  amaurotic  family 
idiocy. 

Microgyria.1® — This  condition  may  be  the  result  of  a  pri- 


"  Anton,  G. :  Hydrocephalien.  Entwickelungsstorungen  des  Gehirns. 
Handb.  der  Patholog.  Anatomie  des  Nervensystems.  II  Abth.,  Berlin, 
1903. 

"Journal  of  Nervous  and  Mental  Diseases,  1887,  1892. 

16  Probst,  M. :  Zur  Lehre  von  der  Mikrocephalie  u.  Mikrogyrie.  Arch, 
f.  Psych,  u.  Nervenheilk.,  Bd.  xxxviii,  H.  1,  1904. 


246  PSYCHIATRY 

mary  disturbance  in  the  development  of  the  brain  (true  micro- 
gyria), or  may  be  caused  by  an  active  disease  process  directly 
affecting-  the  cortical  tissues  during  fetal  life.  This  category 
also  includes  congenital  defects  of  the  cortex,  in  which  there  is 
a  striking  diminution  in  the  size  of  the  convolutions  as  well  as 
of  the  cortical  substance.  The  histological  examination  of  the 
sections  through  the  cortex  in  these  cases  reveals  a  variety  of 
changes.  In  some  instances  the  neuroglia  layer  is  increased  in 
breadth ;  the  number  of  nerve-cells  is  diminished  and  their  posi- 
tion and  arrangement  are  irregular.  The  vessels  and  mem- 
branes in  cases  of  true  microgyria  are  seldom  affected,  but 
where  there  has  been  a  superficial  inflammation  the  existence  of 
the  usual  changes  may  be  demonstrated. 

Heterotopia. — An  abnormal  distribution  of  the  gray  sub- 
stance— although  due  to  developmental  anomalies  in  the  fetus — 
may  occasionally  exist  even  in  adults  without  giving  rise  to 
signs  of  alienation.  The  gray  substance  may  contain  ele- 
ments similar  to  those  seen  in  the  normal  cortex  or  basal 
ganglia,  or  may  be  completely  changed  by  a  preexisting  hydro- 
cephalus (Virchow). 

Porencephalia,  or  loss  of  brain  tissue,  represents  a  great 
variety  of  lesions,  for  a  full  description  of  which  the  reader  is 
referred  to  the  text-books  on  pathology  and  to  the  monographs 
of  Shirras  and  others. 

The  majority  of  these  lesions  occur  in  the  beginning  of 
intra-uterine  life.  In  a  comparatively  large  number  of  cases, 
however,  the  porencephalic  defects  are  acquired  during  life,  par- 
ticularly in  the  earlier  years,  and  have  been  found  in  the  mesial 
or  basal  surface  of  the  hemispheres,  in  the  central  island,  in  the 
temporal,  parietal,  frontal,  and  occipital  convolutions,  while  in 
a  comparatively  large  number  of  cases  the  basal  ganglia  were 
also  affected. 

Hydrocephalus. — Under  this  category  are  included  the 
cases  in  which  there  is  a  marked  increase  in  the  quantity  of  the 
cerebrospinal  fluid.  The  quantity  normally  contained  in  the 
brain  is  supposed  to  vary  from  60  to  150  cubic  centimetres.  In 
the  mild  cases  of  hydrocephalus  it  varies  from  200  to  400  cubic 


HYDROCEPHALUS  AND  MICROCEPHALUS      247 

centimetres,  but  cases  are  reported  in  the  literature  in  which  the 
total  quantity  was  more  than  five  litres.  A  great  variety  of 
changes  are  noted  in  this  condition.  The  ventricles  are  dilated, 
and  as  a  result  of  the  pressure  various  lesions  are  noted  in  the 
brain  substance  in  the  cortex,  basal  ganglia,  cerebellum,  spinal 
cord,  and  medulla. 

The  terms  micro encephalus  and  mkrocephalus  include  all 
the  disturbances  in  the  development  of  the  nervous  system 
which  result  in  such  a  diminution  in  the  size  of  the  brain  and 
skull  as  to  cause  a  marked  disproportion  between  these  and  the 
other  portions  of  the  body.  An  abnormal  smallness  of  the  brain 
and  skull  which  occurs  in  dwarfs — nanocephalus — inasmuch  as 
it  is  a  symmetrical  diminution,  is  a  condition  that  is  different 
from  the  one  under  discussion.  The  cases  of  microcephalus 
proper  may  be  grouped  in  two  categories :  ( 1 )  The  simple  cases 
in  which  there  has  been  a  marked  impairment  in  the  develop- 
ment of  the  brain  without  a  residuary  pathological  process. 
Associated  with  this  there  is  a  corresponding  proportional  lack 
of  development  in  the  bony  covering.  (2)  Cases  in  which  the 
proportional  relations  between  the  brain  and  skull  are  markedly 
disturbed.  This  type  was  described  by  Giacomini  as  pseudo- 
microcephalus.  This  form  of  the  microcephalic  brain  does  not 
represent  merely  a  miniature  of  the  normal  condition,  for  there 
is  often  a  considerable  asymmetry  noticeable  in  the  development 
of  various  convolutions.  The  histological  changes  have  been 
studied  by  a  number  of  observers  and  have  been  shown  to  in- 
clude a  variety  of  lesions.  In  some  cases  the  number  of  the 
nerve-cells  is  markedly  decreased.  Frequently  there  is  an  irreg- 
ularity in  the  arrangement  of  the  elements. 

The  causes  of  hydrocephalus  and  microcephalus  are  too 
complex  and  varied  to  be  discussed  in  the  present  chapter.  Of 
the  various  monographs  on  this  subject  the  most  comprehensive 
is  probably  the  one  by  Anton,17  which  also  contains  a  review  of 
the  literature. 

From  what  has  been  already  said,  it  will  be  seen  that  the 


Op  cit. 


248  PSYCHIATRY 

pathology  of  the  defect  psychoses  cannot  be  comprehensively 
treated  in  a  text-book  on  psychiatry.  The  various  complica- 
tions in  the  nervous  system  associated  with  the  lesions  to  which 
reference  has  been  made  cannot  even  be  enumerated.  Under  the 
head  of  acquired  idiocy  or  imbecility  are  grouped  a  number  of 
cases  which  are  due  to  lesions  occurring  during  the  earlier  years 
of  life— organic  brain  disease,  meningitis,  trauma,  etc.  Refer- 
ence is  also  made  to  this  same  subject  in  the  discussion  of  or- 
ganic brain  diseases  and  their  relation  to  alienation. 

The  diagnosis  of  idiocy,  except  during  the  earlier  stages  of 
infancy,  is,  as  a  rule,  not  difficult. 

The  following  table,  based  by  Church  and  Peterson  upon 
the  observations  of  Preyer  with  some  slight  modifications,  is  of 
use  as  an  aid  to  diagnosis : 

Circumference  of  skull  in  both  sexes  at  birth,  36  cm.  Transverse 
diameter,  22  cm.     Naso-occipital,  22  cm. 

At  the  end  of  the  first  year  the  circumference  is  increased  by  from 
8  to  10  cm. ;  the  transverse  by  from  4  to  5  cm. ;  the  naso-occipital  by  from 
8  to  10  cm. 

Ireland  considers  that  the  term  microcephalic  is  applicable  to  all  heads 
of  adults  below  17  inches,  or  431  mm.,  in  circumference.  In  hydro- 
cephalic skulls  examined  by  Humphrey  the  greatest  circumference  was 
from  23.5  to  25.5  inches. 

Normal  child : 

1st  to  3d  day. — Sensitive  to  light. 

2d  to  3d  day. — Reaction  to  touch. 

4th  day. — Evidences  of  audition. 

7th  day. — Sensibility  to  taste. 

nth  day. — Notices  candle,  facial  reaction  suggesting  pleasure. 

23d  day. — Tears. 

26th  day. — Smiles. 

30th  day. — Vowel  sounds. 

1st  month. — Taste,  smell,  touch,  sight,  hearing.  Sleeps  two  hours  at  a 
time,  16  hours  out  of  24. 

2d  month. — Occasional  strabismus.  Recognizes  human  voice.  Turns 
head  towards  sound.  Pleased  with  music  and  with  human  faces.  Laughs 
at  tickling  and  clasps  with  its  four  fingers  at  the  8th  week.  First  con- 
sonants, 43d  to  51st  days. 

3d  month. — Cries  of  joy  at  sight  of  mother  or  father.  Eyelids  not 
completely  raised  when  the  child  looks  up.  Knows  sound  of  watch  at 
9th  week ;    listens  with  attention. 

4th    month. — Eye    movements    perfect.      Sees    objects    move    towards 


DEFECT    PSYCHOSES  249 

the  eye.  Joy  at  seeing  itself  in  mirror.  Poses  thumb.  Head  held  up  per- 
manently.   Able  to  sit  up  with  support  to  back. 

14th  week. — Beginning  to  imitate. 

5th  month. — Discriminates  strangers.  Pleasure  of  crumpling  and 
tearing  newspapers,  pulling  hair,  or  ringing  bell.  Sleeps  10  or  11  hours 
without  food.    Consonants  1  and  k.    Seizes  and  carries  objects  to  mouth. 

6th  month. — Raises  itself  to  sitting  posture.  Laughs,  raises  and  drops 
arms  when  pleasure  is  great. 

7th  month. — Astonishment  shown  by  open  mouth  and  eyes.  Turns 
head  as  sign  of  refusal. 

8th  month. — Astonished  at  new  sounds  and  sights. 

9th  month. — Stands  on  feet  without  support  Claps  hands  for  joy. 
Fear  of  dog.  Turns  over  when  laid  face  down.  Turns  head  to  light 
when  asked  where  it  is.  Questions  understood  before  child  can  speak. 
Voice  more  modulated. 

10th  month. — First  attempts  at  walking. 

nth  month. — Sitting  has  become  habit  of  life.  Stands  without  sup- 
port;  whispering  begins. 

12th  month. — Pushes  chair.    Obeys  command  "  Give  the  hand." 

13th  month. — Says  "  papa"  and  "  mamma." 

14th  month. — Raises  itself  by  chair;  imitates  coughing  and  swinging 
of  arms. 

15th  month. — Walks  without  support.     Understands  ten  words. 

16th  month. — Runs  alone. 

17,  18th,  19th  months. — Sleeps  10  hours  at  a  time;  associates  words 
with  objects  and  movements.  Blows  horn,  strikes  with  hand  or  foot; 
waters  flowers ;  tries  to  wash  hands,  to  comb  and  brush  hair,  and  to 
execute  other  imitative  movements. 

20th  to  24th  months. — Marks  with  pencil  on  paper ;  executes  orders 
with  surprising  accuracy. 

25th  to  30th  months. — Distinguishes  colors.  Makes  sentences  of  several 
words.    Begins  to  climb  and  jump  and  to  ask  questions. 

30th  to  40th  months. — Goes  upstairs  without  help.  Clauses  formed, 
words  distinctly  spoken.     Influence  of  dialect  appears.     Much  questioning. 

Frequently  the  occurrence  of  hydrocephalus,  micro- 
cephalus,  or  some  other  physical  deformity  directs  the  attention 
of  the  parents  to  certain  deficiencies  in  reactions  of  the  child  to 
the  simpler  forms  of  stimulation.  Failure  to  take  the  breast, 
inability  to  fix  its  eyes  upon  objects  or  to  follow  them  may  be 
noted  early.  Only  gradually,  however,  in  the  majority  of 
cases  do  the  defects  in  intelligence  become  apparent.  Anoma- 
lies of  dentition  are  often  very  marked,  and  it  has  been  calcu- 
lated that  some  degree  of  abnormality  in  this  respect  is  found 
in  over  90  per  cent,  of  the  cases.     The  primary  dentition  is 


250 


PSYCHIATRY 


greatly  delayed.  The  teeth  are  irregular  in  form  and  fre- 
quently appear  with  marked  intervals.  Diminution  in  the  num- 
ber is  not  uncommon.  Erosions  which  are  commonly  attributed 
to  syphilis  are  noted.  The  presence  of  any  of  the  physical  de- 
fects to  which  reference  has  already  been  made,  particularly 
those  affecting  the  skull,  may  be  of  great  aid  in  establishing  a 
diagnosis  during  the  early  period  of  infancy.  This  is  particu- 
larly true  in  regard  to  the  failure  of  the  fontanelles  to  close  or 
the  premature  ossification  of  the  bones  of  the  skull. 

The  diagnosis  in  the  acquired  defect  psychoses  is  fre- 
quently more  difficult  than  is  the  case  in  the  congenital  types.  In 
children  the  recognition  of  the  milder  forms  depends  largely 
upon  the  history  obtained.  It  is  not  necessary  to  repeat  what 
has  already  been  said  in  regard  to  the  various  symptoms.  In 
the  milder  cases  the  defects  in  intelligence  first  become  marked 
when  the  children  go  to  school.  It  is  then  found  that  they  are 
unable  to  keep  up  with  their  classes,  that  their  attention  lapses 
easily,  that  they  fail  to  take  a  normal  interest  either  in  their 
studies  or  companions.  In  addition  to  the  psychic  degeneration 
there  may  be  evidences  of  ethical  defects  or  emotional  anoma- 
lies. Many  of  these  symptoms  may  occur,  especially  at  the  time 
of  puberty,  in  other  conditions,  but  in  the  defect  psychoses  the 
individual  simply  fails  to  develop  intellectually,  emotionally,  and 
ethically,  and  there  are  no  progressive  signs  of  marked  aliena- 
tion. As  dementia  prsecox  sometimes  occurs  in  feeble-minded 
children,  this  combination  may  give  rise  to  difficulties  in  diag- 
nosis. But  the  appearance  of  stereotypy,  mannerisms,  the  cat- 
atonic excitement — which  is  essentially  different  from  that  seen 
in  excited  idiots  or  imbeciles — are  all  features  that  are  in  a 
measure  characteristic  of  the  progressive  psychosis.  The  occur- 
rence of  physical  symptoms — the  Argyll-Robertson  pupil,  the 
absence  of  knee-jerks  and  disturbances  of  speech — serve  to  dis- 
tinguish the  youthful  cases  of  dementia  paralytica  from  idiocy 
and  imbecility. 

The  following  scheme,  slightly  modified  from  one  pro- 
posed by  Heller,  could  be  used  to  good  advantage  in  schools  in 
endeavoring  to  determine  the  number  of  pupils  present  who 


DEFECT    PSYCHOSES  25 1 

show  mental  deficiencies  sufficiently  marked  to  warrant  their 
removal  to  special  institutions : 

Name. 

Age. 

Religion. 

Profession  or  occupation  of  parents. 

Residence.  Location  in  city.  If  in  a  house,  the  number  of  rooms  and 
occupants. 

General  surroundings. 

Evidences  of  poor  heredity.  Alcoholism,  mental  diseases,  suicide, 
criminality,  relationship  of  parents ;    lues,   tuberculosis. 

Brothers  and  sisters.  Ages,  occupations,  any  facts  bearing  upon  their 
mental  and  physical  characteristics. 

Development  of  the  child.  At  what  age  did  it  begin  to  walk  and 
speak?     Evidences  of  rhachitis. 

State  of  nutrition.    Height.    Weight.     Circumference  of  skull. 

History  of  illnesses.  Convulsions.  St.  Vitus'  dance.  Brain  diseases. 
Injury  to  the  skull  or  nervous  system. 

Physical  anomalies  and  signs  of  degeneracy.  Paralyses,  headaches, 
defects  in  speech,  hearing,  or  vision ;    mouth  breathing. 

Traits.  Cleanliness,  dirtiness,  truthfulness,  lying,  a  tendency  to  steal, 
apathy,  irritability,  hypersensitiveness,  imaginativeness,  forgetfulness,  su- 
perficiality, sexual  anomalies. 

Particular  inclinations  and  capabilities.  Music.  Manual  dexterity. 
Character  of  writing,  and  power  to  calculate. 

Treatment ,18 — The  treatment  of  the  defect  psychoses  can 
not  be  entered  upon  in  detail  in  a  general  text-book.  Broadly 
speaking,  idiotic  children  are  much  better  off  in  an  institution 
than  they  are  at  home.  Those  who  exhibit  some  capability  of 
being  trained  should  be  placed  in  an  institution  where  there  are 
especially  appointed  teachers.  As  regards  the  excited  type  of 
idiocy,  it  is  particularly  desirable  that  these  defectives  should  be 
removed  from  their  surroundings,  especially  if  there  are  other 
children  in  the  family,  as  they  are  frequently  subject  to  impulses 
and  anomalous  emotional  states  which  may  be  a  source  of  great 
danger,  not  only  to  themselves  but  to  those  about  them.  Fur- 
thermore, their  condition  is  rendered  worse  by  the  petty  annoy- 
ances and  teasing  to  which  they  are  too  often  exposed.    Again, 

18  Weygandt,  W. :  Die  Behandlung  idiotischer  u.  imbeciller  Kinder  in 
arztlich.  u.  padagog.  Beziehung.  Wiirzburg,  1900.  Heller,  T. :  Grundriss 
der  Heilpadagogik.    Leipzig,  1904. 


252 


PSYCHIATRY 


it  is  not  uncommon  for  these  children  to  be  given  to  excessive 
masturbation,  and  generally  speaking  they  are  unfit  associates 
for  other  children.  The  most  appropriate  training  is  usually 
one  in  which  manual  traits  are  cultivated  and  pedagogy  plays 
an  altogether  minor  part.  Not  infrequently  the  results  that  may 
be  obtained  from  skilful  training  are  remarkable  in  the  milder 
grades  of  idiocy  and  imbecility.  Many  of  these  unfortunates 
can  be  taught  not  only  to  take  care  of  themselves,  to  feed  and 
dress  themselves,  but  also  to  undertake  various  of  the  simpler 
forms  of  employment,  such  as  light  work  about  the  farm  or  in 
the  house.  Imbeciles,  particularly  those  of  the  higher  grades, 
can  be  rendered  capable  of  gaining,  if  not  a  livelihood,  at  least 
some  recompense  for  their  labors — which,  among  the  poorer 
classes  of  society,  is  highly  desirable.  As  these  children  learn 
largely  from  imitation,  great  care  should  be  taken  that  the  exam- 
ples put  before  them  to  imitate  should  be  the  most  appropriate 
possible.  All  forms  of  overexertion,  physical  or  mental,  should 
be  prohibited ;  the  children  should  live  as  much  as  possible  out- 
of-doors  ;  the  diet  should  be  carefully  regulated  and  proper  pre- 
cautions taken  against  the  various  accidents  to  which  their  con- 
dition exposes  them.  Gastro-intestinal  disturbances  are  not  un- 
common, inasmuch  as  such  individuals  are  apt  to  bolt  their  food 
without  masticating  it,  and  frequently  eat  whatever  is  put  be- 
fore them  without  exercising  the  slightest  judgment  as  to  qual- 
ity or  quantity.  Obstinate  constipation  is  not  infrequent.  On 
account  of  the  general  lowering  in  the  mental  and  physical 
faculties  these  unfortunates  are  particularly  susceptible  to  vari- 
ous forms  of  infection — tuberculosis,  pneumonia,  and  the  exan- 
themata— and  their  vitality  is,  as  a  rule,  far  lower  than  that  of 
normal  children. 

Operative  interference  in  cases  of  microcephalus  has 
proved  barren  of  results.  Nor  is  this  surprising,  since  it  has 
been  shown  that  the  condition  is  not  due  solely  to  the  early 
ossification  and  too  rapid  closing  of  the  sutures,  the  changes 
in  the  bony  vault  being  only  a  part  of  the  whole  disease  process. 
The  milder  grades  of  congenital  mental  defects  are  not  uncom- 
monly  found   among  children   attending  the  public  schools. 


DEFECT    PSYCHOSES 


253 


These  individuals  suffer  from  a  method  of  education  for  which 
they^  are  not  adapted ;  nor  is  it  desirable  that  they  should  be 
allowed  to  associate  with  other  children.  Unfortunately,  up  to 
the  present  time  only  in  Germany  is  any  serious  attempt  being 
made  to  remove  these  mentally  deficient  children  from  the 
public  schools  and  place  them  in  institutions  where  they  can  be 
properly  cared  for.  When  there  is  any  reason  to  believe  that 
syphilis  has  been  an  important  etiologic  factor,  the  children 
may  be  given  mercury  or  the  iodides.  Not  infrequently  the 
administration  of  calomel  is  followed  by  slight  temporary  im- 
provement. In  rachitic  imbeciles  careful  attention  should  be 
paid  to  the  diet.  It  should  be  nutritious  but  plain,  made  up 
largely  of  milk,  eggs,  fish,  and  green  vegetables,  with  only  a 
little  meat.  Life  in  the  open  air  and  gymnastics  under  medical 
direction  are  also  indicated.  Cod-liver  oil,  the  syrup  of  the 
iodide  of  iron,  arsenic,  and  phosphorus  often  prove  beneficial. 


CHAPTER    X 

PSYCHOSES    WHICH    ARE    PROBABLY    IN    PART    THE    RESULT    OF 
AN    AUTOINTOXICATION  x 

These  may  be  conveniently  considered  under  the  follow- 
ing headings :  A.  The  so-called  infectious  or  fever  deliria. 
This  category  includes  all  forms  of  mental  aberration  asso- 
ciated with  febrile  diseases  and  not  forming  an  integral  part 
of  other  psychoses.  B.  The  acute  or  collapse  delirium.  C. 
The  subacute  delirious  or  confusional  states  variously  described 
as  amentia,  acute  hallucinosis,  delirious  mania,  acute  confu- 
sional insanity,  and,  finally,  Korsakow's  symptom-complex. 

A.  The  Fever  Deliria.  In  a  description  of  the  fever 
epidemic  of  1836  Schweich  cites  a  reference  from  the  obser- 
vations made  by  an  eye-witness  of  a  somewhat  similar  condi- 
tion in  the  year  1580  to  the  effect  that  "some  had  a  severe 
bleeding,  some  were  out  of  their  heads  and  babbled,  but  such 
was  only  a  sweating  delirium."  Sydenham  and  others  of  the 
earlier  writers  directed  attention  to  the  not  infrequent  associa- 
tion of  fever  with  mental  disturbances,  and  Esquirol  tried  to 
establish  a  definite  causal  relation  between  these  occurrences. 
Schlager,  in  1857,  described  many  of  the  features  of  the 
typhoid  psychoses,2  and  Weber,3  in  1865,  directed  the  attention 
of  physicians  more  especially  to  the  forms  of  alienation  asso- 
ciated with  acute  diseases.     Mental  aberration  of  varying  de- 

1  For  the  bibliography  see  Adler :  Ztschr.  f.  Psych.,  Bd.  liii,  p.  740, 
and  Ballet,  Traite  de  la  Pathologie  Mentale.     Paris,  1903,  p.  330. 

2  See  also  Farrar,  Clarence  B. :  On  the  Typhoid  Psychoses.  Medical 
Reports  of  the  Sheppard  and  Enoch  Pratt  Hospital,  1903,  vol.  i,  No.  1, 
p.  42.  Friedlander,  A. :  Ueber  den  Einfluss  des  Typhus  abdominalis  auf 
das  Nervensystem.  Berlin,  1901.  Siemerling:  Ueber  Psychosen  nach 
akuten  u.  chronisch.  Infektionskrankheiten.  Allg.  Ztschr.  f.  Psych,  u. 
psych. -gericht.  Medizin,  Bd.  lxi,  H.  1  and  2. 

3  Weber,  Hermann :  On  Delirium  or  Acute  Insanity  during  the  De- 
cline of  Acute  Diseases,  etc.     Med.-Chirurg.  Trans.  1867,  xlviii,  p.  135. 

254 


FEVER    PSYCHOSES  255 

grees  of  intensity  and  of  length  of  duration  has  been  reported 
in  connection  with  practically  all  the  febrile  diseases.  The 
frequency  of  these  psychic  manifestations  depends  upon  a 
number  of  conditions,  such  as  the  nature  of  the  disease, 
the  severity  of  the  epidemic,  the  time  of  life  at  which  the  in- 
dividual is  affected.  It  has  been  estimated  that  from  2  to  4 
per  cent,  of  all  mental  disorders  are  referable  to  an  attack 
of  some  acute  infectious  disease.  In  some  countries  at  least 
3.5  per  cent,  of  the  cases  of  insanity  are  attributed  to  typhoid 
fever.  Physicians  have  long  recognized  the  fact  that  the 
severer  epidemics  of  influenza  were  in  a  comparatively  large 
percentage  of  the  cases  particularly  apt  to  be  followed  by  men- 
tal trouble.  The  character  of  the  alienation  was  variously  de- 
scribed as  mania,  hypochondriasis,  melancholia,  or  depression 
associated  with  suicidal  tendencies.  Berkley  and  Jelliffe  4  are 
among  those  who  have  more  recently  directed  the  attention  of 
physicians  in  this  country  to  the  importance  of  this  disease  as 
productive  of  various  forms  of  alienation.  The  latter  par- 
ticularly has  emphasized  the  fact  that  a  great  increase  in  the 
number  of  suicides  occurred  during  the  decade  in  which  in- 
fluenza was  prevalent  as  compared  with  that  prior  to  the 
appearance  of  this  malady.  Although  this  increase  can  not  be 
attributed  solely  to  the  appearance  of  influenza,  the  fact  can  not 
be  doubted  that  this  disease  has  been  instrumental  in  adding 
materially  not  only  to  the  number  of  cases  of  alienation,  but  to 
the  severer  forms  in  which  the  impulse  to  self-destruction  is  a 
common  symptom.  Women  who  suffer  from  an  acute  infec- 
tious disease  are  somewhat  more  prone  to  show  signs  of  aliena- 
tion than  are  men,  and  the  greatest  number  of  cases  are  noted 
in  both  sexes  during  the  prime  of  life.  Nevertheless,  even 
very  young  children  are  by  no  means  exempt.5  This  group 
may  be  subdivided  into:    (a)  The  prefebrile  delirium,  a  con- 

4 Jelliffe,  Smith  Ely:  Influenza  and  the  Nervous  System.  Phila.  Med. 
Journal,  1902,  Dec.  27,  p.  1041. 

8  Heinemann,  M. :  Ueber  Psychosen  u.  Sprachstorungen  nach  acut. 
fieberhaften  Erkrankungen  in  Kinderalter.  Arch.  f.  Kinderheilkunde,  Bd. 
xxxvi,  p.  173-195. 


256  PSYCHIATRY 

dition  that  frequently  gives  rise  to  serious  errors  in  diagnosis; 
(b)  the  more  common  delirious  state  developing  during  the 
height  of  the  fever;  (c)  the  post- febrile  psychoses.  These 
last,  properly  speaking,  begin  at  varying  intervals  after  the 
temperature  has  begun  to  subside  and  their  main  clinical  char- 
acteristics— if  they  are  not  a  part  of  other  psychoses  such  as 
manic-depressive  insanity  or  dementia  prsecox — are  not  essen- 
tially different  from  those  of  collapse  delirium  or  amentia.  Ab- 
normal psychic  states  may  develop  during  the  course  of  any 
febrile  disease,  and,  furthermore,  it  is  important  to  note  that  a 
fever  may  be  an  important  etiological  factor,  not  only  in  these 
but  also  in  other  forms  of  alienation. 

(a)  In  the  first  subdivision  the  dominant  symptoms, 
according  to  Farrar,  are  ( 1 )  impaired  associative  activity ;  (2) 
disorientation;  (3)  psychomotor  excitement;  (4)  fallacious 
sense  perceptions  with  developing  delusions ;  ( 5  )  anxious  affec- 
tive states.  As  a  rule,  for  some  time  prior  to  the  onset  of  the 
mental  malady  the  patient  has  been  in  poor  health,  has  been 
nervous,  sleeping  poorly,  showing  considerable  motor  restless- 
ness, more  marked,  probably,  at  night.  There  is  an  inability 
to  focus  the  attention  and  considerable  impairment  in  associa- 
tive memory.  Symptoms  of  a  general  psychomotor  restless- 
ness, not  limited  to  the  functions  of  speech,  are  more  common 
in  these  cases  than  in  those  in  which  there  are  psychomotor 
retardation  and  depression.  This  slight  psychic  aberration  de- 
velops several  days  before  the  more  acute  symptoms,  but  occa- 
sionally, when  the  toxaemia  seems  to  be  more  intense,  the  pro- 
dromal period  may  be  absent,  or,  if  it  exist  at  all,  is  only  of  a 
few  hours'  duration  and  then  immediately  passes  over  into  the 
stage  of  acute  delirium.  Such  a  condition  is  sometimes  met 
with  in  the  exanthemata,  typhoid  fever,  pneumonia,  influenza. 
The  patient  after  feeling  sick  for  a  few  hours  or  days  sud- 
denly becomes  wildly  maniacal.  Such  cases  carry  with  them  a 
grave  prognosis  and  occur  generally,  though  not  always,  in  in- 
dividuals who  have  an  hereditary  predisposition.  In  addition 
to  the  symptoms  already  referred  to,  it  is  important  to  note 
that  there  is  apt  to  be  considerable  disturbance  in  the  reception 


FEVER    PSYCHOSES  257 

and  elaboration  of  sensory  stimuli,  which  in  most  cases  gives 
rise  to  illusions  which  are  generally  of  a  disagreeable  or  terri- 
fying character.  The  sound  of  voices,  of  people  walking  in  the 
wards,  and  all  ordinary  forms  of  auditory  stimuli  are  at  once 
misinterpreted  by  the  patient  and  render  him  unduly  apprehen- 
sive and  anxious.  Associated  with  the  illusions  there  are,  as  a 
rule,  very  vivid  hallucinations  which  constantly  change  in 
character.  This  combination  of  symptoms  may  give  rise  to  a 
disorientation  and  incoherence  so  complete  as  to  amount  to 
asymbolism.  The  increase  in  the  number  of  illusions  and 
hallucinations  is  generally  associated  with  still  greater  motor 
restlessness,  the  refusal  of  food,  and  the  exaggeration  of  all 
the  somatic  symptoms.  In  some  instances  there  is  a  continuous 
and  rapid  progression  in  all  the  symptoms  and  the  patient  dies 
without  the  occurrence  of  any  break  in  the  delirium.  In  other 
cases  lucid  intervals  intervene  and  persist  for  several  hours  at 
a  time,  so  that  the  patient  to  a  certain  degree  becomes  rational, 
appreciative  of  what  is  going  on  about  him,  and  shows  a  fair 
degree  of  orientation.  In  some  cases  the  initial  delirium  passes 
over  directly  into  an  abnormal  mental  state,  which  persists  not 
only  during  the  acme  but  after  the  subsidence  of  the  febrile 
symptoms,  only  disappearing  long  after  the  drop  in  tempera- 
ture has  occurred.  In  rare  instances  the  delirious  stage  is  not 
accompanied  by  any  fever  and  the  mental  symptoms  subside 
as  the  temperature  rises. 

The  prognosis  in  these  cases  of  initial. delirium  is  generally 
more  unfavorable  than  in  those  in  which  the  mental  aberration 
makes  its  appearance  later  on  in  the  disease.  Not  only  is  there 
a  greater  danger  that  the  alienation  may  persist  for  a  con- 
siderable period  of  time  or  end  in  a  paranoiic  state,  but  the 
gravity  of  the  prognosis,  so  far  as  the  disease  itself  is  con- 
cerned, is  generally  worse.  The  severe  forms  of  initial  delirium 
in  typhoid  fever  and  acute  articular  rheumatism  with  a  high 
temperature  (41  °  to  44  °  C.)  are  particularly  dangerous.  The 
percentage  of  mortality  in  all  cases  varies  somewhat  according 
to  different  observers,  but  the  average  of  all  available  statistics 
is  between  40  and  50  per  cent. 

17 


258  PSYCHIATRY 

(b)  The  great  majority  of  delirious  states,  since  they  de- 
velop during  the  height  of  the  disease,  belong  to  this  second 
subdivision.  This  is  particularly  true  in  regard  to  typhoid 
fever,  pneumonia,  influenza,  acute  rheumatism,  meningitis,  and 
the  various  exanthemata.  The  symptoms  may  not  differ  essen- 
tially from  those  already  described  as  belonging  to  the  pre- 
febrile  deliria,  except  that  in  the  majority  of  cases  the  onset  is 
more  gradual.  There  is  nearly  always  considerable  inter- 
ference with  the  transmission  of  sensory  impulses,  psychic 
anaesthesias,  paresthesias,  or  hyperesthesias  sometimes  appear- 
ing, generally  associated  with  hallucinations  and  -delusions. 
Consciousness  is  almost  never  unclouded.  The  degree  of  motor 
restlessness  varies  greatly  in  different  individuals,  sometimes 
being  so  intense  that  the  patient  can  be  restrained  only  with  the 
greatest  difficulty,  while  in  other  instances  it  is  limited  to 
spasmodic  twitchings  or  incoordinated  choreiform-like  move- 
ments of  the  extremities.  At  times  there  develop  twitchings 
of  the  facial  muscles  and  some  interference  with  the  muscles  of 
speech,  more  rarely  with  those  of  deglutition.  These  cases, 
according  to  the  severity  of  their  symptoms,  may  be  subdivided 
into  four  groups  (Kraepelin).  (1)  Those  in  which  the  cloud- 
ing of  consciousness  is  most  marked,  but  in  which  strange 
organic  sensations  are  present.  The  motor  restlessness  varies 
from  a  mere  fidgetiness  to  more  pronounced  forms.  The 
patient  complains  of  headache  and  various  feelings  of  discom- 
fort. His  sleep  is  broken  and  he  is  apt  to  suffer  from  un- 
pleasant dreams.  (2)  The  symptoms  are  somewhat  increased 
in  intensity,  and  hallucinations  and  delusions,  particularly  those 
of  a  dream-like  character,  begin  to  make  their  appearance. 
These  latter,  as  a  rule,  are  strange  and  grotesque,  and  are 
both  visual  and  auditory  in  character.  (3)  Here  we  meet  with 
a  marked  increase  in  the  number  of  the  symptoms,  more  or 
less  complete  disorientation,  and  a  diminution  or  entire  loss 
of  appreciation  by  the  patient  that  he  is  ill,  a  marked  exag- 
geration of  the  motor  restlessness,  varying  emotional  states 
characterized  by  great  intensity  as  regards  their  expression. 
Furthermore,  there  is  an  exaggerated  tendency  to  talk  and  a 


FEVER    PSYCHOSES 


259 


sensory  flight  of  ideas.  (4)  In  the  severest  cases  there  is  com- 
plete disorientation,  consciousness  is  very  markedly  affected, 
external  impressions  produce  practically  no  reaction;  the  pa- 
tient, when  not  comatose,  talks  continuously  in  a  low,  mum- 
bling tone,  and  periods  of  coma  vigil  and  lethargy  are  of 
frequent  occurrence. 

The  symptoms  generally  continue  as  long  as  the  fever 
lasts,  and  may  then  disappear  after  the  defervescence;  on 
the  other  hand,  they  may  persist  for  a  considerable  period  of 
time,  until  finally  one  of  two  things  happens, — either  the  patient 
gets  well  or  else  he  passes  over  into  a  paranoiic  condition. 
The  intensity  of  the  mental  symptoms  does  not  seem  to  bear 
any  definite  relation  to  the  height  of  the  fever  or  the  rapidity 
of  the  pulse.  The  mental  disturbances  occurring  during 
typhoid  fever  are  supposed  to  be  more  or  less  specific,  and 
yet  a  careful  study  would  show  that  they  do  not  differ  essen- 
tially from  those  which  may  occur  in  other  febrile  disorders 
of  equal  duration.  The  intensity  of  the  febrile  delirium  varies- 
greatly  in  different  cases. 

The  diagnosis  of  these  conditions  is  not  difficult.  The 
prognosis  is  always  grave,  and  becomes  more  so  when  the  men- 
tal symptoms  persist  after  the  fall  in  the  temperature. 

The  treatment  in  the  prefebrile  as  well  as  in  the  febrile 
deliria  is  largely  symptomatic.  If  the  patient  is  not  too  excited, 
the  cold  pack  may  be  used  with  great  benefit.  Ice-bags  may  be 
kept  applied  to  the  head.  If  the  patient  is  not  too  weak,  the 
full  bath  is  often  very  efficacious.  Sometimes  it  is  advisable 
in  dealing  with  very  excited  patients  to  begin  with  water  at 
about  blood-heat  and  then  gradually  reduce  the  temperature. 
The  nursing  of  these  patients  is  all-important.  In  well- 
equipped  hospitals,  where  there  are  plenty  of  skilful  nurses  and 
abundant  opportunity  for  carrying  out  hydrotherapeutic  meas- 
ures, the  camisole  and  other  artificial  means  of  restraint  are 
practically  never  indicated.  Moreover,  hydrotherapy  will  gen- 
erally render  unnecessary  the  administration  of  hypnotics  and 
sedatives  of  various  kinds  which  are  often  detrimental  in  these 
cases.     Saline  infusions  are  often  very  effective. 


26o  PSYCHIATRY 

(c)  The  post-febrile  psychoses  may  for  the  sake  of  con- 
venience be  divided  into  two  groups :  ( i )  those  occurring 
coincidently  with  or  soon  after  the  subsidence  of  the  tem- 
perature; (2)  those  developing  more  slowly  and  after  a 
longer  lapse  of  time.  As  has  already  been  pointed  out,  fever 
in  itself  may  be  an  etiologic  factor  of  great  importance  in 
the  development  of  almost  any  form  of  alienation,  such  as 
dementia  praecox,  manic-depressive  insanity,  etc.,  although  it 
can  never  be  regarded  as  a  causative  agent  specific  for  any  one 
type.  After  the  drop  in  temperature  has  occurred  or  during 
the  period  of  convalescence  acute  delirious  or  confusional  con- 
ditions may  develop,  a  description  of  which  is  given  in  the 
following  section.  At  present  it  is  the  general  consensus  of 
opinion 6  that  the  pathological  changes  which  occur  in  the 
central  nervous  system  as  the  result  of  elevations  of  the  bodily 
temperature  are  to  be  regarded  as  the  results  of  autointoxica- 
tions ;  but  the  manner  in  which  the  toxines  act  is  still  a  mys- 
tery, and  as  yet  no  definite  relationship  can  be  established 
between  the  lesions  and  the  clinical  symptoms.  Formerly 
considerable  importance  was  erroneously  attached  to  the  sup- 
posed hyperaemic  or  anaemic  condition  of  the  cerebral  vessels. 
Such  conditions  may  be  the  result  merely  of  preagonal  or  post- 
mortem changes,  or  due  to  the  alterations  in  the  position  of 
the  body.  Nevertheless  it  is  always  possible  to  say,  from  in- 
spection of  the  central  nervous  system,  particularly  in  sections 
treated  with  the  Nissl  stain,  that  the  individual  previous  to 
death  has  suffered  from  pyrexia.  In  the  nerve-cells,  as  a  rule, 
very  marked  changes  are  demonstrable.  They  show  a  ten- 
dency to  stain  diffusely,  this  feature  probably  being  the  result 
of  the  dissolution  of  the  chromatic  substance  and  its  diffusion 
throughout  the  cell.  The  nucleus  is  sometimes  swollen  and 
eccentric;  the  processes,  particularly  the  axis  cylinder,  show 
a  strong  tendency  to  stain  deeply.  Some  observers  have  re- 
ported fragmentation,  particularly  of  the  apical  processes  and 
axis  cylinders.7 

8  Friedlander,  Goldscheider,  Aschaffenburg. 
7  Meyer,  E. :    Orth's  Festschrift. 


PLATE   I 


Ganglion  cell.    Xissl  stain.    X   750.    Spencer,  \  horn,  immers.  obj.    (Cramer  isoch.  plate.) 


PLATE   II 


Normal  Betz  cell.    Nissl  stain.     X  750.    Spencer,  ^  horn,  immers.  obj.    (Cramer  isoch.  plate.) 


PLATE    III 


r. 


*#* 


Fever  cell.     X  750.     Diffuse  staining  of  cell-body,  nucleus,  and  processes.     The  intercellular 
substance  is  also  stained.     Spencer,  £  hom.  inimers.  obj.     (Cramer  isoch.  plate.) 


PLATE    IV 


Fever  cells  showing  diffuse  staining  of  cell-body,  nucleus,  and  processes.     X  75°-     Spencer, 
&-  hom.  immers,  obj.     (Cramer  isoch.  plate.) 


PLATE  V 


t  "  •  ' 


Large  pyramidal  cell,  ant.  cent,  convolution  (Bethe  stain).  X  iooo.  A,  axis  cylinder ; 
L,  lateral  basal  processes.  The  intercellular  substance,  which  is  not  stained  in  I  and  II,  and 
is  indicated  in  III,  in  this  preparation  is  easily  recognizable. 


THE    ACUTE   DELIRIUM  26l 

In  some  of  the  acute  intoxication  psychoses  mitotic  figures 
are  demonstrable  in  the  glia. 

The  nerve-fibres  are  sometimes  affected  in  the  severer 
cases,  showing  degeneration  of  the  myelin  sheaths  and  the  for- 
mation of  small  globular  masses.  In  the  protracted  cases, 
particularly  the  typhoid  psychoses,  fatty  degenerations  are 
noted  in  various  parts  of  the  nervous  system.  Micro-organisms 
— the  typhoid,  influenza,  and  tubercle  bacillus,  the  pneumo- 
coccus  and  various  other  forms,  as  well  as  the  parasite  of 
malaria — are  often  found  in  the  central  nervous  system.  What 
relations  these  organisms  bear  to  the  pathological  changes  and 
to  the  clinical  symptoms  is  not  clear,  but  it  is  generally  supposed 
that,  in  the  majority  of  instances  at  any  rate,  they  are  of  only 
secondary  importance  and  that  the  invasion  has  often  taken 
place  just  before  death. 

B.  The  Acute  Delirium.  Collapse  Delirium.  Delirium 
Grave.  Phrenomania.  Bell's  Disease. — Frequent  references, 
more  or  less  definite  in  character,  occur  throughout  medi- 
cal literature 8  to  a  form  of  aberration  bearing  a  striking 
similarity  in  certain  particulars  to  the  type  seen  in  infectious 
diseases  and  characterized  by  an  acute  onset  with  severe 
somatic  disturbances.  Calmeil  9  first  suggested  the  name  of 
the  acute  delirium,  but  it  remained  for  Weber,10  under  the 
title  of  collapse  delirium,  to  give  a  detailed  and  accurate  clini- 
cal account  of  this  group  of  symptoms.  The  unity  of  the 
various  clinical  pictures  was  first  emphasized  by  certain  French 
clinicians  (Chaslin),  but  great  credit  is  due  to  the  Heidel- 
berg school  for  recognizing  a  similar  origin  and  develop- 
ment for  these  cases,  despite  the  fact  that  at  first  sight  their 
symptoms  are  strikingly  dissimilar.  Nor  does  this  union  upon 
a  common  basis  have  any  reference  to  the  supposed  bacillary 
factor  in  the  etiology, — a  theory  advocated  principally  by  the 
Italians, — but  is  derived  from  the  fundamental  analysis  of  these 


Hippocrates :     Coelius  Aurelianus.     Thomas  Willis. 
Traite  des  mal.  inflam.  du  cerveau.  t.  i,  p.  142. 
0  Med.  Chir.  Trans.,  vol.  xlvii,  p.  135.    London,  1865. 


262  PSYCHIATRY 

conditions,  the  result  of  experimental  studies  made  by  Krae- 
pelin  and  others  into  the  nature  of  fatigue. 

The  malady  is  characterized  by  a  marked  interference  with 
the  mental  functions,  disturbances  of  sensation  and  motion, 
and  in  from  40  or  50  per  cent,  of  the  cases  a  favorable 
termination  after  a  period  varying  from  several  days  to  two 
or  three  weeks.  It  makes  its  appearance  in  neurotic  individ- 
uals who  have  been  subjected  to  severe  psychic  shocks  or  during 
the  period  of  defervescence  after  febrile  diseases — such  as  the 
exanthemata,  typhoid  fever,  pneumonia,  erysipelas,  influenza — 
or  after  severe  trauma,  parturition,  or  surgical  operations. 
Generally,  after  the  prodromal  period,  which  may  vary  from  a 
few  hours  to  several  days,  the  patient  begins  to  suffer  from 
motor  anomalies  of  the  hyperkinetic,  parakinetic,  or  akinetic 
type,  with  accompanying  psychic  anaesthesias,  paresthesias,  or 
hyperesthesias,  and  various  kinds  of  hallucinations,  which 
are  particularly  apt  to  take  on  a  fantastic  and  bizarre  character, 
the  patients  complaining  that  they  see  various  animals,  angels, 
or  devils.  In  the  earlier  stages  these  hallucinations  are  likely 
to  be  dream-like  in  character  and  seldom  dominate  the  actions 
of  the  individual,  but  gradually  the  sensory  plainness  becomes 
exaggerated  and  their  reflex  power  greatly  increased.  Soon 
states  of  apprehensiveness  and  marked  anxiety  develop.  The 
patient  is  distracted  or  frenzied  by  the  apparitions  which  seem 
to  hover  about  his  bed,  and  may  even  attempt  to  escape  from 
them  by  covering  his  head  with  the  bedclothes  or  frequently, 
if  not  watched,  by  resorting  to  other  and  more  desperate  means, 
in  his  blind  fury  attacking  nurses  or  physicians.  As  the  dis- 
order progresses,  disorientation  becomes  more  and  more  com- 
plete and  he  becomes  unable  to  recognize  his  surroundings, 
declaring  at  one  moment  that  he  is  in  heaven,  or  again  affirm- 
ing with  equal  emphasis  that  he  is  in  prison  or  in  the  depths 
of  hell.  The  identity  of  those  about  him  is  frequently  con- 
fused; the  nurse  or  the  physician  is  claimed  as  an  intimate 
friend  or,  when  the  emotional  state  has  changed,  is  regarded 
with  suspicion  or  terror.  As  the  irritability  increases,  the 
speech-centres  are  almost  never  left  unaffected  and  the  inco- 


THE    ACUTE    DELIRIUM  263 

herence  increases.  The  motor  disturbances  may  be  so  exag- 
gerated that  all  coordinated  movements  are  seriously  impaired. 
Consciousness  is  greatly  clouded.  The  affective  state  is  one 
in  which  inexplicable  impulses  dominate  the  cerebral  activity 
and  all  forms  of  associative  memory  are  greatly  impaired.  In 
some  instances  the  reactions  of  the  patient  and  the  content  of 
the  ideas  expressed  may  at  times  suggest  the  typical  flight  of 
ideas  of  the  maniacal  patient.  But  as  a  rule  the  incoherence 
becomes  greater,  the  individual  is  less  responsive  to  external 
stimuli,  and  disorientation  is  frequently  more  marked  and  con- 
sciousness more  clouded.  In  some  cases  the  character  of  the 
delirium  is  less  boisterous,  the  motor  restlessness  not  promi- 
nent, and  the  patient's  appearance  suggests  the  low  muttering 
delirious  state  of  typhoid  fever.  In  still  another  type  of  the 
disease  the  individual  hallucinations  are  not  as  dominant  and 
those  that  exist  are  less  evanescent  in  character,  while  certain 
forms  of  auditory  or  visual  hallucinations  seem  to  be  more  or 
less  constantly  in  the  field  of  the  patient's  attention  and  an 
explanation  or  systematization  of  these  phenomena  may  be 
attempted  by  him.  Periods  of  mental  depression  may  alternate 
with  those  of  excitement  or  stupor.  These  cases  are  extremely 
difficult  to  differentiate  from  the  other  psychoses,  particularly 
amentia. 

The  physical  symptoms  which  occur  during  the  course  of 
the  acute  delirium  are  manifold,  although  none  are  specific. 
On  this  point,  however,  certain  writers  hold  a  different  view.11 
During  the  prodromal  period  we  meet  with  anorexia,  nausea, 
vomiting.  In  some  cases,  in  addition  to  the  psychic  hyperes- 
thesias alluded  to,  there  are  peripheral  disturbances  in  sensa- 
tion. At  other  times  there  are  painful  areas  over  the  site  of 
some  internal  organ,  particularly  in  the  cardiac  and  epigastric 
regions.  As  the  disease  develops,  there  may  be  a  rise  in  tem- 
perature, 390  to  41  °  C.  not  being  uncommon,  and  a  more  or 
less  sudden  drop  just  prior  to  death  is  sometimes  noted.    Cases 


11  Pritchard,  W.  B. :    Delirium  Grave.    The  Journ.  of  Nerv.  and  Merit. 
Diseases,  vol.  xxxi,  March,  1904,  No.  3. 


264  PSYCHIATRY 

are  observed  in  which  there  is  no  febrile  rise,  and  even  sub- 
normal temperatures  occur  quite  frequently.  During  the  acme 
of  the  delirium  the  patient  gives  every  appearance  of  an  indi- 
vidual suffering  from  a  severe  toxaemia.  The  face  has  a  pecu- 
liar drawn  appearance,  the  complexion  is  sallow,  the  eyes  are 
somewhat  sunken,  the  tongue  is  thick  and  coated,  and,  as  the 
motor  restlessness  becomes  greater,  there  seems  to  be  consid- 
erable difficulty  in  articulation.  The  loss  of  weight  is  marked, 
and  a  rise  in  the  curve,  even  if  the  mental  state  is  unchanged, 
generally  indicates  a  more  favorable  prognosis.  Sometimes 
a  patient  will  gain  several  pounds  in  two  or  three  days. 

The  gastro-intestinal  disturbances  are  generally  pro- 
nounced. Sometimes  the  nausea  and  vomiting  are  so  obsti- 
nate that  no  food  can  be  retained  and  a  resort  to  artificial 
feeding  becomes  necessary.  In  other  instances  the  refusal  to 
take  food  is  the  result  of  delusions.  The  breath,  as  a  rule,  is 
fetid  and  constipation  is  marked,  although  at  times  a  watery 
diarrhoea  supervenes.  The  urine  is  often  scanty,  of  high  spe- 
cific gravity,  and,  according  to  numerous  observers,  is  very 
toxic  in  its  qualities,  a  statement,  however,  that  does  not 
always  hold  good.  The  chlorides  are  frequently  diminished 
and  traces  of  albumin  and  sugar  are  not  uncommon.  Cer- 
tain investigators  have  found  an  increase  in  the  quantity  of 
indican  and  uric  acid.  At  times  there  may  be  an  unusual 
flow  of  saliva.  The  skin  in  the  cases  with  a  high  temperature 
is  dry,  but  in  the  asthenic  types  of  the  disease  is  moist  and 
covered  with  a  cold,  clammy  sweat.  The  latter  is  particularly 
noticeable  in  fatal  cases.  Not  uncommonly  the  patients, 
particularly  in  the  severe  types  of  the  disease,  suffer  from 
epileptiform  or  mild  apoplectiform  attacks,  the  occurrence 
of  which  has  sometimes  been  responsible  for  a  diagnosis  of 
general  paresis.  In  rare  instances  disturbances  in  the  eye- 
muscles  and  in  the  reflexes  to  light  are  noted.  As  would  natu- 
rally be  expected,  the  skin  and  tendon  reflexes  show  no  essen- 
tial difference  from  those  belonging  to  all  stages  of  excitement 
and  are,  as  a  rule,  markedly  increased. 

Termination.1 — At  least  50  per  cent,  of  the  patients  sue- 


THE   ACUTE   DELIRIUM  265 

cumb.  In  venturing  a  prognosis  the  character  of  the  physical 
symptoms  should  always  be  allowed  great  weight.  The  out- 
look is  generally  worse  where  the  motor  restlessness  is  excessive 
or  the  patient  shows  signs  of  collapse,  the  pulse  becoming 
small  and  rapid  and  the  stomach  rejecting  nourishment.  The 
delirium  runs  its  course  within  a  few  hours  or  several  days, 
and,  when  a  favorable  outcome  is  to  be  expected,  usually  ter- 
minates, as  do  many  of  the  cases  of  delirium  tremens,  the 
patient  falling  into  a  prolonged  sleep. 

Much  can  be  accomplished  in  the  way  of  treatment.  A 
great  deal  depends  on  the  nursing,  and  these  individuals  are 
far  better  off  in  a  good  general  hospital  than  in  any  asylum 
imperfectly  equipped  in  this  respect.  Moreover,  in  view  of 
the  difficulties  attending  the  nursing  of  such  patients  in  pri- 
vate houses,  any  attempt  to  care  for  them  at  home  is  usually 
unjustifiable.  One  or  more  nurses  must  be  in  constant  at- 
tendance, so  that  everything  possible  may  be  done  to  relieve 
the  symptoms  as  speedily  as  possible.  Although  such  patients 
frequently  struggle  furiously  to  get  away  from  their  attend- 
ants, trying  to  jump  out  of  the  window  or  to  injure  themselves 
in  various  ways,  mechanical  restraint  should  not  be  resorted 
to  until  appropriate  hydrotherapeutic  measures  have  been  tried 
and  failed.  In  practically  all  cases,  if  the  warm  continuous 
bath  is  properly  given,  being  supplemented,  if  necessary,  by 
small  doses  of  some  hypnotic,  it  will  have  the  desired  effect. 
The  bath  should  be  given  with  great  care,  and  at  first  one  of 
the  resident  physicians  should  keep  within  call  for  some  time 
in  order  to  note  the  effects. 

The  methods  of  procedure  are  described  in  detail  in  the 
chapter  on  Treatment.  (Cf.  page  151.)  When  the  patient 
is  once  in  the  tub  he  is  better  off  than  in  bed.  The  duration 
of  the  bath  may  be  varied  according  to  circumstances, — from 
five  minutes  to  several  hours,  if  necessary.  When  the  tem- 
perature is  high  or  the  patient  shows  evidences  of  marked 
toxaemia,  saline  infusions  are  often  useful.  A  tendency  to 
collapse  may  be  combated  by  the  administration  of  alcohol, 
coffee,  camphor,  digitalis,  or  strychnine.     The  administration 


266  4  PSYCHIATRY 

of  narcotics  should  be  resorted  to  only  when  the  bath  has  failed 
to  quiet  the  restlessness,  but,  if  it  becomes  necessary,  small 
doses  of  bromide,  sulfonal,  trional,  and  in  exceptional  cases 
scopolamin  may  be  given.  Every  means  should  be  employed 
to  keep  up  the  nutrition.  Small  quantities  of  milk  should  be 
given  regularly  every  two  hours  combined  with  raw  eggs  or 
bouillon.  If  the  stomach  rejects  nourishment,  nutritive  ene- 
mata — from  two  to  three  in  twenty-four  hours — are  indicated. 
Sometimes  high  rectal  injections  of  normal  saline  solution  at 
body  temperature  are  of  great  value  in  preventing  collapse. 

The  pathology  of  this  condition,  as  far  as  it  is  known, 
will  be  described  in  the  following  chapter. 

C.  Subacute  States  of  Delirium  and  Mental  Con- 
fusion. Amentia  (Meynert).12  Acute  Confusional  In- 
sanity, Delirious  Mania,  Hallucinatory  Insanity. 
Hallucinatory  Confusion,  Paranoia  Dissociativa 
(Ziehen). — The  distinguishing  features  in  the  forms  of  alien- 
ation to  be  described  under  this  head  are  clouded  consciousness, 
interference  with  associative  memory,  hallucinations  and  de- 
lusions, as  well  as  anomalous  emotional  states,  such  as  appre- 
hensiveness  and  fear.  No  sharp  line  divides  this  from  the 
group  of  cases  just  described.  The  malady,  when  uncompli- 
cated, runs  its  course  in  from  six  or  eight  weeks  to  several 
months,  and  does  not  include  any  conditions  that  are  to  be 
regarded  as  belonging  to  other  forms  of  alienation.  The  line 
between  the  more  protracted  cases  of  the  acute  delirium  and 
these  clinical  forms  can  only  be  drawn  arbitrarily,  as  there 
are  no  distinctive  features.  Although  individuals  may  suffer 
from  more  than  one  attack,  many  of  the  so-called  recurrent 
cases  not  improbably  represent  phases  in  other  psychoses,  such 
as  manic-depressive  insanity,  dementia  precox,  dementia  para- 
lytica. A  great  many  of  these  confusional  states  can  only  be 
differentiated  from  the  acute  delirium  by  their  more  prolonged 

12  Meynert,  Die  acut.  hallucin.  Formen  des  Wahnsinns  u.  ihre  Verlauf. 
Allgemein.  Ztschr.  f.  Psych.,  xxxviii.  Jahrbuch  f.  Psych.,  1881.  Chaslin: 
La  confusion  mentale  primitive,  1895.  Del.  Greco :  Sulle  varie  forme  die 
confusione  mentale.     II  Manicomio  moderno,  1897  and  1898. 


AMENTIA  267 

duration.  The  older  authors,  particularly  Pinel,  Esquirol, 
Georget,  Griesinger,  Kahlbaum,  described  a  variety  of  con- 
ditions, the  majority  of  which  may  be  included  under  this 
head;  but  it  was  not  until  Meynert  studied  this  syndrome 
that  the  probable  unity  of  the  various  clinical  pictures  became 
apparent.  This  conclusion  has  been  more  recently  extended 
and  confirmed  by  the  investigations  carried  on  concerning  the 
nature  of  fatigue  and  the  possibility  that  exhaustion  is  a  factor 
of  specific  and  fundamental  importance  in  this  group  of  psycho- 
ses. Wernicke,13  however,  still  emphasizes  what  he  considers 
to  be  essential  dissimilarities  in  the  varieties  of  cases  forming 
this  group. 

The  onset  of  the  disease  in  many  cases  is  not  essentially 
different  from  that  of  the  acute  delirium,  especially  in  those 
instances  in  which  the  malady  runs  a  somewhat  prolonged 
course.  After  the  prodromal  period,  following  one  of  the 
causes  to  which  reference  will  be  made  later,  the  patient  shows 
signs  of  restlessness,  slight  dissociation  in  connected  thought, 
mild  apprehensiveness,  and  fear  of  being  left  alone,  and  not 
infrequently  complains*  of  being  troubled  by  unpleasant 
thoughts  or  by  frightful  dreams  when  he  gets  to  sleep. 
Sometimes  gradually,  at  other  times  within  a  short  space 
of  time,  the  disturbances  in  associative  memory  become  more 
marked,  the  distractibility  increasing  so  that  the  attention  is 
constantly  wandering.  Even  when  asked  a  simple  question, 
the  patient  may  say  a  few  words  and  then,  becoming  oblivious 
of  what  was  uppermost  in  his  mind,  pass  to  another  topic. 
Distractibility,  however,  is  not  the  chief  feature,  as  it  is  in 
maniacal  excitement,  in  which  sensory  impressionability  is 
apt  to  be  very  great.  Sensory  impressions  easily  deflect  the 
patient's  attention,  but,  on  account  of  the  clouded  conscious- 
ness, they  do  not  give  a  definite  trend  to  the  subsequent  re- 
actions. On  account  of  the  rapid  deflections  in  the  attention, 
memory  suffers  greatly  and,  since  all  sense  impressions  are 
evanescent,  the  patient  forgets  in  a  few  minutes  the  events 

13  Grundriss  der  Psychiatrie,  406. 


268  PSYCHIATRY 

that  have  just  transpired.  The  face  sometimes  assumes  an 
anxious  expression;  marked  tremor  may  develop  and  often 
slightly  incoordinated  and  involuntary  contractions  of  the 
facial  muscles  are  present.  If  the  patient  is  asked  to  fix  the 
eyes  upon  an  object,  the  request  is  not  complied  with  for 
more  than  an  instant.  The  disturbances  in  sensibility,  as 
a  rule,  are  similar  to  those  in  the  acute  delirium  and  may 
be  considered  to  be  of  psychic  origin.  Gradually  the  halluci- 
nations become  more  marked.  At  first  they  are  generally  of 
a  primary  character, — flashes  of  light,  sounds  of  bells  or  of 
running  water.  But  soon  the  ordinary  noises  about  the  wards 
begin  to  be  misinterpreted.  The  sighing  of  the  wind  is  evi- 
dence of  the  passing  of  unseen  spirits;  the  sounds  made  by 
patients  in  other  parts  of  the  ward  become  the  voices  of  friends 
calling  for  help.  Frequently  the  patient  complains  of  an  un- 
pleasant taste  in  the  mouth,  which  is  regarded  as  a  sign  that 
his  food  has  been  poisoned.  Shapes  of  curious  animals — 
snakes,  lizards,  horrid  monsters — are  seen.  Not  infrequently 
these  fallacious  sense  perceptions  result  in  insane  ideas  of 
persecution,  and  the  patient  affirms  that  the  nurses  and  physi- 
cians are  trying  hard  to  kill  him.  Sometimes  the  grotesque 
phantasms  or  frightful  apparitions  suggest  the  mental  disturb- 
ances in  epilepsy.  In  the  earlier  stages  the  hallucinations  are 
constantly  changing.  Each  new  impulse  seems  to  start  up  a 
sensory  flight  of  ideas.  At  times  the  motor  restlessness,  which 
is  nearly  always  present  early  in  the  disease,  is  associated  with 
considerable  garrulity,  and  the  content  of  what  is  said  and 
the  character  of  the  speech  reaction  may  suggest  the  flight 
of  ideas.  But  the  dulling  of  consciousness,  the  lack  of  agree- 
ment between  the  external  surroundings  and  what  is  said,  as 
well  as  the  absence  of  other  symptoms^  help  to  distinguish 
the  conversation  of  these  patients  from  that  of  the  typical 
maniac.  As  the  disease  progresses,  the  rapid  change  in  the 
character  of  the  hallucinations  and  illusions  becomes  less 
marked.  Certain  forms  show  a  tendency  to  persist,  and  to 
these  the  patient  is  constantly  referring.  As  the  flightiness 
diminishes,   there  is   a  greater  tendency  shown  towards   the 


PLATE   VI 


At  the  time  this  photograph  was  taken  the  patient  was  in  a  state  of  great  mental  confusion. 


AMENTIA  269 

development  of  definite  ideas  of  persecution  or  self-accusation; 
patients  refer  to  themselves  as  lost  souls  without  hope  and 
eternally  damned.  If  any  form  of  external  stimulation  affects 
them,  it  is  apt  to  increase  the  states  of  apprehensiveness  or 
anxiety,  so  that  the  dominating  force  of  the  hallucinations  and 
illusions  becomes  overwhelming.  The  motor  restlessness 
varies  from  a  mild  uneasiness  to  the  wildest,  most  incoordinated 
and  excessive  movements.  At  times  the  incoordination  and 
the  explosiveness  of  certain  acts  suggest  exaggerated  forms  of 
chorea. 

The  consciousness  of  the  individual  is,  as  a  rule,  greatly 
disturbed,  although  moments  of  apparent  quiet  and  lucidity 
may  come  and  go. 

The  physical  symptoms  of  amentia  during  the  earlier  and 
more  acute  stages  do  not  differ  essentially  from  those  of  the 
acute  delirium,  although  the  loss  of  weight  is  not  usually  so 
rapid  and  the  physical  signs  are  less  prominent.  During  the 
excited  period  the  pulse  frequently  becomes  rapid  and  small; 
at  times  during  the  course  collapse  symptoms  may  develop. 
The  reflexes  are  nearly  always  increased ;  the  temperature  may 
rise  during  the  periods  of  greatest  excitement  or  less  commonly 
falls  below  the  normal. 

Course. — The  clinical  course  of  the  disease  varies  greatly 
and  is  associated  with  a  variety  of  mental  symptoms.  The 
two  principal  types  of  the  disease  are  similar  to  those  described 
under  the  head  of  the  acute  delirium, — an  asthenic  type  and 
one  in  which  the  confusional  state  is  more  boisterous  and  the 
general  motor  restlessness  greater.  To  the  former  belongs 
the  confusional  or  stuporous  amentia  of  Meynert;  to  the 
latter,  the  hallucinatory  confusion,  delirious  amentia,  and  the 
so-called  acute  hallucinatory  paranoia  of  other  writers.  The 
following  table,  taken  from  Ballet,14  gives  some  idea  of  the 
variety  of  mental  states  which  are  temporarily  grouped  to- 
gether under  this  head : 

14  Traite  de  la  Pathologie  Mentale. 


270  PSYCHIATRY 

Asthenic  mental  confusion  Cerebral  torpor 

Stupidity 
Acute  dementia 

Hallucinatory  mental  confusion Depressed  form 

Mixed  form 
Systematized  delirium 


Unquestionably  many  of  the  states  frequently  grouped 
under  this  head  in  reality  represent  stages  of  other  psychoses. 
Great  confusion  in  grouping  has  arisen  from  the  fact  that 
many  of  the  clinical  records  mention  merely  the  symptoms  of 
a  single  attack,  without  giving  any  information  as  to  the 
previous  history  of  the  individual  or  as  to  his  condition  after 
leaving  the  institution. 

Termination. — In  a  large  number  of  cases  recovery  takes 
place,  although,  more  particularly  in  the  asthenic  types,  not 
a  few  of  the  patients  die  during  the  earlier  stages  in  collapse. 
In  the  former  the  manifestations  suggest  a  protracted  acute 
delirium.  The  duration  for  the  most  part  is  between  three 
and  six  months.  Some  cases  undoubtedly  pass  over  into  a 
chronic  paranoiic  state  which  may  persist  for  months  and 
sometimes  never  entirely  clears  up. 

The  prognosis  depends  upon  a  variety  of  factors,  largely 
upon  the  physical  condition  of  the  patient.  In  the  asthenic 
types  constant  and  recurrent  attacks  of  heart  weakness  are 
to  be  regarded  as  ominous.  The  persistence  of  the  insane 
ideas,  more  particularly  when  they  are  well  systematized,  gen- 
erally means  that  the  case  will  run  a  long  course,  and  the  prog- 
nosis for  ultimate  recovery  is  correspondingly  worse.  Not 
uncommonly  patients  die  from  some  intercurrent  trouble.  On 
account  of  their  lowered  vitality  and  poor  nutrition,  they  are 
particularly  susceptible  to  pneumonia,  infections  of  various 
kinds,  tuberculosis,  and  so  on.  A  more  or  less  rapid  increase 
in  the  bodily  weight  is  nearly  always  a  favorable  sign. 

Incidence. — As  happens  also  in  the  acute  delirium,  females 
are  attacked  more  often  than  males.  Although  abroad  the 
disease  seems  to  be  of  comparative  infrequency,  according  to 
Kraepelin  representing  only  one-half  per  cent,  of  all  the  cases 


AMENTIA 


271 


of  alienation,  it  is  probable  that  a  comparatively  large  number 
of  cases  occur  in  this  country.  The  same  opinion  has  recently 
been  expressed  in  regard  to  the  frequency  of  its  incidence  in 
Vienna. 

The  history  of  the  following  case  is  of  interest  on  account 
of  the  occurrence  of  catatonic  symptoms.  When  the  patient 
was  first  seen,  a  provisional  diagnosis  was  made  of  dementia 
praecox,  but,  as  the  mental  confusion  and  hallucinations  gradu- 
ally disappeared,  and  a  complete  recovery  without  any  signs 
of  mental  reduction  followed,  a  revised  diagnosis  of  amentia 
was  substituted : 


Miss  X,  aged  32.  Nationality,  U.  S.  A.  Admitted  November  9,  1903 ; 
discharged  February  15,  1904.  Patient  confused.  History  obtained  from 
mother,  sister,  and  nurse. 

Family  History. — Mother  living,  rather  delicate.  Father  died  of  pneu- 
monia at  63.  Four  brothers  living  and  well.  One  brother  died  of  "  abscess 
of  the  brain."  Two  sisters  living,  one  delicate.  Both  sisters  and  brothers 
are  nervous. 

Personal  History. — Measles,  chicken-pox,  whooping-cough,  and  scarlet 
fever  in  childhood.  No  other  acute  diseases.  Strong  and  well  until  about 
16,  when  she  began  to  have  some  menstrual  trouble,  which  has  continued 
off  and  on  ever  since.  At  this  time  she  nursed  her  grandmother  for  some 
months  during  a  severe  illness,  and  this  strain  was  followed  by  "  nervous 
prostration."  She  blamed  herself  for  not  having  done  more,  but  the  sister 
affirms  that  the  patient  worried  without  cause,  as  there  was  no  reason  for 
self-reproach.  Some  years  after  her  health  was  tolerable.  For  eleven 
years  she  was  in  "  ill  health."  Cause  not  known.  Ten  years  ago  she 
went  to  a  hospital  as  a  probationer  nurse,  but  she  found  that  she  worried 
excessively  and  always  feared  that  she  had  not  done  things  correctly. 
Eight  years  ago  two  brothers  had  typhoid  fever.  She  nursed  them  and 
worried  greatly  over  their  condition.  One  brother  died  from  abscess  of 
the  brain  following  middle-ear  disease,  and  the  patient  reproached  herself 
greatly,  as  she  thought  she  could  have  done  something  to  prevent  this. 
Since  then  she  has  never  been  quite  well  and  has  had  one  nervous  attack 
after  the  other.  Has  travelled  about  a  good  deal  and  seen  many  physi- 
cians. Some  of  them  made  a  diagnosis  of  hysteria.  No  especial  features 
were  noted  beyond  these  until  October,  1901,  when  she  had  an  attack  of 
sciatica,  together  with  severe  pain  and  loss  of  power  in  the  arms.  She 
became  weak  and  helpless  and  her  condition  caused  much  alarm.  She 
gradually  recovered  from  the  sciatica  and  spent  some  months  in  bed. 
In  the  spring  of  1902  she  was  able  to  be  up,  but  was  very  nervous.  The 
appetite  has  usually  been  poor.  She  has  been  subject  to  headaches  for 
several  years.     Average  weight,  108  pounds. 


272 


PSYCHIATRY 


Present  illness  began  September  20,  1903.  She  complained  of  weakness 
in  both  arms  and  apparently  was  unable  to  feed  herself.  In  about  two 
weeks  this  disappeared  and  the  power  in  her  hands  returned.  When  the 
question  came  up  as  to  where  she  would  pass  the  winter,  she  began  again 
to  complain  of  weakness  in  her  arms.  She  went  to  bed  and  was  prescribed 
for  by  a  physician.  Later  it  was  noticed  that  she  was  dull  mentally  and 
did  not  seem  to  comprehend  clearly  what  was  said  to  her  about  business 
affairs.  She  had  difficulty  in  counting  money.  At  this  time  there  were 
no  hallucinations  or  delusions.  Four  or  five  days  later,  when  seen  by 
her  mother  and  sister,  a  great  change  was  noticed.  She  seemed  to  recog- 
nize people  about  her,  but  talked  in  a  rambling  way.  She  was  then 
brought  to  Baltimore.  While  on  the  train  she  was  restless  and  hard 
to  control  and  had  an  idea  that  people  were  being  killed. 

October  21,  1903 :  There  were  some  hallucinations  of  sight  and  hearing. 
The  fixed  ideas  relating  to  certain  individuals  whom  she  supposed  to  have 
been  killed  became  more  pronounced  and  persistent.  When  admitted  to 
the  hospital,  she  declared  that  her  father  and  brother  were  dead  and  their 
bodies  were  in  the  next  room.  She  then  began  to  talk  about  a  hansom  cab 
and  an  instant  later  spoke  about  an  epigram  and  later  of  a  monogram.  She 
was  able  to  give  her  name  and  age  correctly,  but  was  not  oriented  for 
place. 

November  9,  1903 :  At  night  she  talked  excessively  in  a  loud  tone  of 
voice.  There  was  no  sense  in  what  she  said.  Marked  distractibility. 
Pupils  large  but  equal.  Tongue  heavily  furred.  On  the  10th  she  was  in  an 
apparent  stupor,  and  could  not  be  aroused  when  spoken  to  in  a  loud  tone 
of  voice.     Haemoglobin,  60  per  cent. 

November  13,  1903 :  The  patient  was  lying  in  bed  on  her  back  with  the 
eyes  partly  closed  and  mouth  open,  snoring  slightly.  Face  expressionless. 
No  marked  mechanical  irritability  of  the  facial  nerve.  Patient  could  be 
tickled  and  pressure  made  over  the  supraorbital  branch  without  much 
effect.  The  toes  and  fingers  could  be  pinched  without  any  apparent 
reaction.  When  the  arms  were  raised,  there  was  a  slight  tendency  for 
them  to  remain  in  the  position  in  which  they  were  placed.  No  response 
to  passive  movement.  It  was  difficult,  though  possible,  to  get  a  response 
to  questions.  The  voice  was  very  feeble.  When  the  second  question 
was  asked,  the  reply  was  nearly  always  a  repetition  of  that  given  to  the 
first.  For  a  few  days  following  there  were  periods  of  restlessness  and 
the  patient  tried  to  get  out  of  bed.  On  one  occasion  the  face,  neck,  and 
hands  suddenly  became  cyanotic.  There  were  slight  convulsive  move- 
ments of  the  face,  neck,  and  extremities.  The  movements  were  not 
violent  nor  extensive.  The  patient  seemed  perfectly  unconscious  for 
about  fifteen  minutes.  On  the  20th  there  was  slight  resistance  to  passive 
movement.  No  attitudinizing.  There  was  disorientation  for  time  and 
space.  She  mistook  the  identity  of  those  about  her,  talked  a  good  deal, 
but  had  no  typical  flight  of  ideas.  The  emotional  state  was  one  of  more 
or  less  indifference.  She  obeyed  simple  commands  promptly.  Distracti- 
bility was  not  very  great. 

A  note  made  on  December  8  states  that  the  patient  had  had  an  ex- 


AMENTIA  273 

cellent  week :   remained  quiet  nearly  all  the  time ;   seemed  perfectly  normal ; 
memory  excellent. 

The  treatment  consisted  in  injections  of  normal  salt  solution,  400  c.c. 
being  given  on  November  15,  after  which  the  procedure  was  repeated  at 
varying  intervals  until  she  became  rational.  In  addition  to  this  she  was  kept 
on  a  strict  rest-cure  and  given  wet  packs.  On  February  15,  1904,  the  patient 
was  discharged  cured.  Careful  examination  failed  to  demonstrate  the 
presence  of  any  mental  impairment.  Weight  on  admission,  go  pounds ;  on 
discharge,  104^  pounds.  Two  months  after  her  discharge  the  patient  was 
reported  to  be  in  excellent  health. 

Age. — The  disorder  is  apt  to  occur  in  individuals  in  the 
prime  of  life.  Cases  have  been  reported  as  occurring  as  early 
as  the  ninth  or  tenth  year  and  some  as  late  as  the  fifth  or  sixth 
decade  of  life.  Nevertheless  it  must  be  said  that  in  the  latter 
instances  the  symptoms  were  atypical,  and  on  account  of  the 
age  of  the  patient  it  is  almost  impossible  to  say  that  the  re- 
corded confusional  state  was  not  a  part  of  some  senile  dis- 
order. 

Etiology. — As  a  rule,  the  family  history  in  individuals 
who  are  afflicted  with  these  acute  confusional  states  is  bad, 
and  the  fact  can  be  elicited  that  one  or  both  parents  have  suf- 
fered from  neuroses  or  definite  psychoses.  Even  as  regards 
cases  which  seem  to  be  of  very  acute  onset,  in  the  majority 
it  will  be  found  that  the  individual  prior  to  the  onset  of 
the  disease  had  been  subject  to  some  form  of  nervous  or  men- 
tal disorder.  Not  uncommonly  we  find  that  such  individuals 
have  always  been  more  or  less  delicate,  that  as  children  they 
have  required  to  be  more  carefully  guarded  than  other  mem- 
bers of  the  family,  and  after  puberty  have  been  subject  to 
anomalous  emotional  states,  attacks  of  so-called  nervous  pros- 
tration, and  a  great  variety  of  symptoms  which  could  belong 
only  to  the  possessor  of  an  unstable  nervous  system. 

The  exciting  causes  of  confusional  insanity  are  in  a  meas- 
ure identical  with  those  provocative  of  the  acute  delirium.  Par- 
turition is  not  infrequently  the  starting-point  of  the  disorder 
in  the  predisposed,  and  gastro-intestinal  disorders  seem  to  be 
intimately  connected  with  not  a  few  of  the  cases.15    For  a  long 

15  Wagner  :  Wien.   klin.   Wchnschr.,    1895. 
18 


274  PSYCHIATRY 

time  prior  to  the  outbreak  of  the  malady  the  patients  frequently 
suffer  from  poor  digestion,  anorexia,  nausea,  constipation 
alternating  with  attacks  of  diarrhoea,  and  a  great  variety  of 
disturbances.  Next  in  importance  are  the  acute  diseases,  par- 
ticularly the  exanthemata,  as  well  as  typhoid  fever  and  influ- 
enza. Mental  and  physical  shock  also  play  an  important  role, 
while  all  forms  of  trauma  seem  to  favor  the  development  of 
this  psychosis. 

Differential  Diagnosis. — The  recognition  of  amentia  is 
frequently  beset  with  many  difficulties.  In  the  earlier  stages 
of  the  disease  the  character  of  the  excitement,  the  appearance 
of  certain  stereotyped  mannerisms,  the  tendency  to  repeat  cer- 
tain words,  and  the  general  mentality  of  the  patient  are  sug- 
gestive of  the  catatonia  of  dementia  prcecox.  The  difficulty 
in  differentiating  the  two  conditions  is  greatly  increased  when 
we  remember  that  these,  as  well  as  other  catatonic  symptoms, 
may  occur  during  the  course  of  amentia,  although  they  are  far 
less  definite  and  noticeable  than  in  cases  of  dementia  prsecox. 
In  amentia  there  are,  as  a  rule,  a  greater  impairment  of  con- 
sciousness and  a  more  general  defect  in  associative  memory. 
The  patient  is  more  confused,  less  impulsive,  and  shows  con- 
siderable difficulty  not  only  in  the  elaboration  but  also  in  the 
reception  of  sensory  impressions.  From  cases  of  manic- 
depressive  insanity  the  differentiation  is  often  difficult,  but  in 
genuine  cases  of  mania  the  flight  of  ideas  has  certain  specific 
qualities,  described  more  fully  elsewhere,  and  the  interference 
with  consciousness  or  with  the  reception  of  all  forms  of  sen- 
sory impressions  is  less  marked.  Occasionally  amentia  may 
be  mistaken  for  dementia  paralytica,  but  the  diagnosis  is  soon 
settled  if  on  careful  physical  examination  somatic  symptoms 
are  detected.  As  regards  chronic  alcoholism,  the  history  as 
well  as  the  general  features  of  the  two  diseases  seldom  leave 
the  physician  in  doubt  as  to  the  real  condition. 

The  treatment  of  amentia  does  not  differ  essentially  from 
that  of  the  acute  psychoses.  During  the  periods  of  excitement 
hydrotherapeutic  measures — full  baths,  warm  packs — saline 
infusions,  careful  nursing,  forced  feeding,  and  protection  of 


AMENTIA 


275 


the  patient  from  self-inflicted  injury  should  be  employed. 
The  drugs  which  may  be  helpful  are  the  same  as  those  used  in 
other  excited  conditions. 

Pathology.1^ — Practically  little  is  known  regarding  the 
pathology  of  these  two  forms  of  alienation.  At  various  times 
observers  have  attempted  to  prove  that  the  acute  delirium  was 
a  cerebral  malady  of  an  infectious  nature,  while  others  main- 
tain that  it  develops  purely  as  the  result  of  an  exhaustion  of  the 
central  nervous  system.  Bianchi  and  Piccinino  17  thought  they 
had  demonstrated  that  a  special  bacillus  found  by  them  in  the 
blood  and  meninges  in  cases  of  the  acute  delirium  played  an 
important  role  in  the  etiology.  These  observations,  however, 
have  not  been  confirmed  by  other  investigators.  Ceni 18  showed 
that  in  the  early  stages  of  the  delirium  no  micro-organisms 
were  present,  and  that  in  other  instances  where  they  appeared 
later  in  the  disease  they  were  of  various  forms.  At  present 
it  is  generally  believed  that  these  micro-organisms  do  not 
bear  any  definite  relationship  to  the  mental  symptoms,  although 
it  is  not  improbable  that  they  may  give  rise  to  secondary  in- 
fections of  a  grave  character.  The  nerve  elements,  as  a  rule, 
show  considerable  alteration.  In  some  instances  we  meet  with 
a  peripheral  chromatolysis,  more  marked  in  the  larger  elements, 
but  generally  the  central  or  perinuclear  disintegration  of  the 
chromatic  substance  involves  most  of  the  cell.  None  of  the 
changes  recorded  are  in  any  sense  specific,  and  it  is  question- 
able how  closely  related  they  are  to  the  mental  symptoms. 
Where   the   patient   has    suffered    from    a   hyperpyrexia,    the 


16  Camia,  Florenz :  Ueber  Veranderungen  an  den  Nervenzellen  bei 
acuten  Psychosen.  Rivista  di  pat.  nervos.  e  ment.,  fasc.  9,  1900.  Bins- 
wanger,  O. ;  Berger,  H. :  Zur  Klinik  u.  patholog.  Anat.  d.  post-infect.- 
u.  Intoxicationpsychosen.  Archiv.  f.  Psych,  u.  Nervenkrankh.,  Bd.  xxxiv, 
H.  1,  1901.  Hoch,  August:  On  Changes  in  the  Nerve-cells  of  the  Cortex 
in  a  Case  of  Acute  Delirium  and  a  Case  of  Delirium  Tremens.  Am. 
Journ.  Insan.  Tomlinson,  H.  A. :  The  Pathology  of  Acute  Delirium. 
Am.  Journ.  Insan.,  1903,  vol.  lx,  No.  9. 

17  Sulla  origine  infettiva  d'una  forma  di  delirio  acuto.  Ann.  di  Nevrol., 
1893,  xi. 

l8Riv.  sper.  di  Fren.,  fasc.  1,  1900. 


276  PSYCHIATRY 

changes  due  to  the  fever  per  se  are  pronounced.  Some  investi- 
gators have  emphasized  a  homogeneous  atrophy  of  the  nu- 
cleus of  the  larger  nerve-cells.  This  is  important  not  as  having 
any  direct  bearing  upon  the  specificity  of  the  change,  but  rather 
as  an  indication  that  cells  thus  affected  can  never  return  to 
their  normal  state.  The  cells  in  the  spinal  ganglion  and 
throughout  the  sympathetic  nervous  system  are  nearly  always 
affected.  Orr  19  and  others  have  called  attention  to  the  fact 
that  there  may  be  marked  alteration  of  the  myelin  sheath  and 
axis-cylinder,  the  myelin  breaking  up  into  little  droplets  or 
oval  globules,  or  in  other  instances  the  axis-cylinder  being 
denuded.  Personally  I  am  inclined  to  believe  that  these  changes 
are  more  directly  the  result  of  the  terminal  pyrexia  than  of 
the  alienation.  In  addition  to  the  changes  in  the  cortex,  a 
variety  of  lesions  in  the  cord  have  been  described.  Turner  20 
and  Camiar  directed  attention  to  the  degeneration  in  the 
pyramidal  columns  in  many  of  the  acute  insanities.  Lesions 
are  frequently  noted  in  the  kidneys,  liver,  and  heart.  These 
include  fatty  degenerations  of  the  cells,  of  the  convoluted 
tubules  or  the  glomeruli  of  the  kidney,  of  the  hepatic  cells, 
and  also  a  degeneration  involving  the  muscular  fibres  of  the 
heart.  It  is  not  at  all  improbable,  as  the  Italian  observers 
have  suggested,  that  the  mental  symptoms  are  the  result  of  an 
autointoxication  induced  by  a  variety  of  conditions,  and  that 
this  primary  toxaemia  so  lowers  the  vitality  of  the  individual 
that  secondary  intoxications  due  to  the  presence  of  micro- 
organisms may  result.21  There  are  so  many  doubtful  points 
involved  in  a  discussion  of  the  pathology  of  these  cases  that 
dogmatic  statements  are  out  of  place.  Orr  is  right  in  saying 
that  only  by  attacking  the  problems  concerned  from  every 
possible  vantage  ground  can  a  better  comprehension  of  the 
nature  of  the  disease  be  attained. 

19  Orr,  David :  A  Contribution  to  the  Pathology  of  Acute  Insanity. 
Brain,  Summer,  1902,  part  xcviii,  p.  240. 

20Journ.  of  Mental  Science,  Oct.,  1900. 

21  D'Abundo,  Agostini :  Rivista  sperimentale  di  Freniatria,  fasc.  iv, 
1900. 


KORSAKOW'S    SYNDROME 


277 


Regarding  the  nature  of  the  pathological  changes  in 
amentia,  practically  nothing  is  known.  Lesions  similar  to 
those  described  as  existing  in  the  febrile  psychoses  or  the  acute 
deliriums  are  frequently  met  with,  but  these  bear  little,  if  any, 
relationship  to  the  symptoms. 

D.  Cerebropathia  Psychica  Tox^emica.  Korsakow's 
Syndrome.  Polyneuritic  Psychosis.  Neurocerebrite 
Toxique.22 — Mention  occurs  in  the  literature,  as  early  as  the 
middle  of  the  last  century,23  of  the  mental  disturbances  met 
with  in  alcoholics  with  accompanying  lesions  in  the  peripheral 
nerves.  In  this  country  the  subject  was  referred  to  by  Mills 
in  1886  and  by  M.  Allen  Starr24  in  1887,  but  this  syndrome 
was  first  described  in  detail  by  Korsakow,25  whose  name  is 
now  commonly  associated  with  this  clinical  picture.  The  work 
of  Soukhanoff,26  Babinski,  and  others  has  shown  that  similar 
mental  disturbances  may  occur  in  cases  in  which  alcohol  does 
not  enter  as  an  etiologic  factor. 

The  psychic  aberration  may  be  briefly  summarized  as  con- 
sisting in  defects  in  associative  memory,  confusion  with  a 
marked  tendency  to  confabulate  and  indulge  in  pseudo-remin- 

22  Tiling,  Th. :  Ueber  alkoholische  Paralyse  und  infektiose  Neuritis 
multiplex.  Halle  a/S.,  1897.  Meyer,  E.,  u.  Raecke,  J. :  Zur  Lehre  vom 
Korsakow's  Symptomcomplex.  Archiv  f.  Psych.,  1903,  Bd.  37,  H.  I. 
Turner,  John :  Twelve  Cases  of  Korsakoff's  Psychosis  in  Women.  Journ. 
of  Mental  Science,  October,  1903.  Miller,  Harry  W. :  Korsakow's  Psy- 
chosis. Report  of  Cases.  Am.  Journ.  Insan.,  lx,  No.  4,  1904.  E.  Dubre : 
Ballet's  Traite  de  la  pathologie  mentale,  1903,  p.  1122. 

23  Magnus  Hiiss,  1849-52. 

24  Middleton  Goldsmith  Lectures,  1887.     Medical  News,  March,  1887. 

25  Trouble  mentale  dans  la  paralysie  alcoolique  et  son  rapport  avec  la 
derangement  de  la  sphere  psychique  dans  la  nevrite  multiple  d'origine  non- 
alcoolique.  Moniteur  russe  de  la  psychiatrie  et  de  la  neuropathologie,  1887, 
t.  iv,  fasc.  2.  Plusieurs  cas  de  cerebropathie  originale  combinee  avec  la 
nevrite  multiple  (cerebropathia  psychica  toxsemica)  :  Gazette  russe  heb- 
domadaire  clinique,  1889,  Nos.  5-7.  Du  trouble  mental  combine  avec  la 
nevrite  multiple  (cerebropathia  psychica  toxsemica)  :  Revue  russe  de 
medecine,  1889,  No.  13,  pp.  3-18. 

29  Revue  russe  de  medecine,  1896,  No.  14,  and  Revue  de  med.,  Mai, 
1897. 


278  PSYCHIATRY 

iscences,  hallucinations,  and  delusions,  whose  character  will 
be  presently  described,  and  marked  fluctuation  in  the  affective 
life.  In  many  of  the  alcoholic  cases  the  syndrome  bears  a 
striking  resemblance  to  certain  forms  of  delirium  tremens, 
and  for  this  reason,  as  well  as  because  alcohol  was  a  causative 
factor  in  so  many  cases,  Bonhoeffer  and  others  have  referred 
to  the  condition  as  a  form  of  chronic  alcoholic  delirium.  In 
the  instances,  which  frequently  come  under  observation,  where 
there  is  a  marked  disturbance  in  the  functions  of  the  peripheral 
nerves,  we  meet  with  anaesthesias,  paresthesias,  or  hyperes- 
thesias more  or  less  directly  referred  to  the  distribution  of 
the  peripheral  nerves,  at  times  an  ataxic  incoordination,  an 
atrophy  of  muscles  (amyotrophies),  a  diminution  or  com- 
plete abolition  of  the  deep  reflexes,  contractures,  permanent 
deformities  due  to  paralysis  and  disturbances  of  the  cranial 
nerves,  ophthalmoplegias,  etc.  These  neuritic  disturbances 
may  or  may  not  precede  the  development  of  the  mental 
symptoms.  In  almost  all  of  the  cases  there  is  a  prodromal 
period  during  which  the  patients  show  signs  of  some  mental 
aberration,  irritability,  at  times  sleeplessness,  at  other  times 
a  marked  drowsiness  or  even  stupor  from  which  they  are 
aroused  only  with  the  greatest  difficulty.  After  the  lapse  of  a 
varying  interval  of  time,  the  characteristic  delirium  makes  its 
appearance.  As  a  rule,  memory  for  the  immediate  past  is 
markedly  defective,  although  the  individual  may  retain  a  rela- 
tively exact  knowledge  of  the  earlier  periods  of  his  life.  The 
attention  of  such  patients  is  easily  gained,  but  is  kept  with  diffi- 
culty and  only  imperfectly.  The  tendency  to  confabulate  and 
indulge  in  pseudo-reminiscences  is  extraordinary  and  is  one  of 
the  most  characteristic  features  in  the  majority  of  the  cases. 
Such  patients  will  frequently  narrate  long  tales  having  every 
semblance  of  truth,  and  yet  upon  investigation  it  will  be  found 
that  they  have  no  substantiation  in  fact.  The  sense  of  recogni- 
tion may  be  greatly  impaired ;  the  patients  do  not  know  those 
about  them,  forget  the  faces  of  members  of  their  own  family 
and  friends,  and  not  infrequently  show  marked  deficiencies  in 
spatial  and  time  orientation.     Not  infrequently  cases  are  met 


KORSAKOW'S    SYNDROME 


279 


with  in  which  the  lacunae  in  memory  do  not  seem  to  follow 
any  rule,  the  patient  remembering,  without  any  particular  rea- 
son being  evident,  certain  events  and  situations  while  apparently 
completely  oblivious  of  others.  The  confusion  which  exists 
and  is  characteristic  of  a  large  number  of  the  cases  depends 
upon  a  great  variety  of  causes,  a  great  part  of  it  being  in  all 
likelihood  referable  to  the  disturbances  in  the  peripheral  tracts 
and  sense  organs.  The  hallucinations  and  delusions  in  a 
measure  resemble  those  present  in  other  toxic  states.  Those 
connected  with  the  visual,  tactile,  and  more  rarely  the  auditory 
sense  are  met  with.  Frequently  the  first  assume  the  form  of 
visions.  In  the  beginning  these  come  to  the  patient  only  at 
night,  but  as  the  disease  progresses  they  become  more  intense 
and  are  present  also  during  the  day.  They  may  or  may  not 
be  of  a  terrifying  character,  giving  rise  to  states  of  great  ap- 
prehensiveness  or  anxiety,  and  sometimes  assume  fantastic, 
bizarre  characteristics  so  commonly  met  with  in  the  toxic 
and  alcoholic  deliria.  The  mental  enfeeblement  is  more  or 
less  marked.  As  a  rule,  this  impairment  is  general  and  not 
limited  to  any  specific  function.  In  opposition  to  the  view 
maintained  by  certain  writers,  I  am  inclined  to  believe  that  the 
critical  faculties  are  always  impaired,  and  for  this  reason  the 
patients  are  more  or  less  credulous  and  open  to  suggestion. 
Except  in  the  severest  forms  the  patients  retain  some  degree 
of  insight  into  and  appreciation  of  their  own  condition,  not  in- 
frequently affirming  that  the  defects  in  memory  and  percep- 
tion incapacitate  them  for  the  performance  of  all  ordinary 
duties. 

The  emotional  states  vary.  Sometimes  the  patient  is  ex- 
hilarated and  the  condition  may  simulate  the  so-called  classical 
type  of  paresis.  In  others  there  is  depression,  although  there 
is  an  absence  27  of  the  self-accusation  noticed  in  true  melan- 
cholia. 

The  clinical  forms  of  the  disease  vary  considerably,  and 


27  Starr,  M.  Allen :  Organic  Nervous  Diseases.     Lea  Brothers  &  Co., 
New  York  and  Phila.,  1903,  p.  124. 


28o  PSYCHIATRY 

in  making  an  attempt  to  differentiate  them  we  must  bear 
in  mind  the  fact  that  certain  syndromes  now  included  under 
this  head  may  eventually  be  found  to  belong  in  another  cate- 
gory. Ballet  describes  the  following  clinical  types :  ( i )  An 
amnestic  form,  in  which  the  chief  feature  is  the  pronounced 
disturbance  of  memory.  Individuals  so  afflicted  show  scarcely 
any  power  of  recollecting  or  redeveloping  events  that  have 
transpired  only  a  few  minutes  before.  The  conversation 
gives  evidence  of  the  extraordinary  tendency  to  indulge  in 
pseudo-reminiscence.  (2)  The  confusional  type.  There  is  a 
greater  interference  with  consciousness,  and  the  patienf  is  more 
or  less  apathetic  and  indifferent  to  his  surroundings,  responding 
feebly,  or  at  times  not  at  all,  to  stimulation.  (3)  The  delirious 
form.  Here  the  psychosensorial  super-production  is  marked. 
Hallucinations  are  varied  and,  although  evanescent,  at  times 
possess  great  sensory  plainness.  In  the  more  protracted  cases 
the  fallacious  sense  perceptions  give  way  to  organized  and  more 
or  less  systematized  ideas  of  persecution  or  negation  and  a 
systematized  delirious  state  develops.  (4)  The  emotional 
type,  in  which  the  apprehensiveness,  anxiety,  phobias,  and  ex- 
aggerated emotional  reactions  give  a  decided  coloring  to  the 
whole  clinical  picture  and  in  which  the  symptoms  come  and 
go  in  an  episodic  form.  (5)  The  dementing  type,  in  which 
there  is  a  still  greater  interference  with  all  forms  of  associative 
activity  and  less  reaction  to  external  stimuli.  These  conditions 
bear  a  striking  resemblance  to  the  stuporous  states  in  typhoid 
fever,  meningitis,  etc.  This  asthenic  dementing  form  may 
terminate  more  or  less  rapidly  in  death. 

Duration. — The  duration  of  the  disorder  varies  within 
wide  limits, — from  a  few  weeks  to  several  months.  Certain 
writers  hold  that  complete  recovery  sometimes  takes  place,  an 
affirmation  which  I  am  at  present  unprepared  either  to  accept 
or  reject.  Unfortunately,  many  of  these  patients,  who  have 
been  treated  in  general  hospitals  or  institutions  devoted  to  the 
care  of  the  insane,  have  not  been  carefully  examined  prior  to 
their  discharge,  and  the  entry  "discharged  cured"  is  frequently 
made  on  the  history  without  any  details  of  the  examination 


KORSAKOW'S    SYNDROME  281 

being  recorded.  Although  on  superficial  examination  these 
patients  may  be  apparently  well,  it  is  probable  that  a  more 
detailed  examination  would  reveal  the  persistence  of  some  slight 
psychic  defect  in  the  majority  of  cases.  Patients  not  infre- 
quently die  during  the  delirium  from  some  intercurrent  com- 
plication. 

Etiology. — A  great  variety  of  opinion  is  still  entertained 
regarding  the  causation.  The  disease  undoubtedly  is  more 
common  during  the  prime  of  life,  but  it  may  occur  in  children 
as  well  as  in  old  people.  Some  writers  affirm  with  great  posi- 
tiveness  that  women  are  more  susceptible  than  are  men  (Chot- 
zen),  whereas  Soukhanoff  and  Boutenko  28  in  a  total  number 
of  192  patients  found  112  males  and  80  females.  That  the 
syndrome  is  undoubtedly  the  result  of  a  toxaemia  is  generally 
conceded,29  but  the  nature  of  the  poison,  which  in  some  in- 
stances affects  the  central  nervous  system  and  in  others  also 
the  peripheral  nerves,  has  not  yet  been  determined.  Although 
at  first  alcohol  was  supposed  to  be  an  etiologic  factor  in  all 
the  cases,  it  is  now  known  that  a  similar  if  not  an  identical  com- 
plex of  symptoms  can  develop  as  the  result  of  other  causative 
agents.  Nevertheless,  although  the  condition  comes  on  occa- 
sionally after  typhoid  fever,  tuberculosis,  gastro-enteritis,  and 
toxic  conditions  due  to  lead,  arsenic,  etc.,  the  majority  of  cases 
are  noted  in  alcoholics.  Within  the  past  decade  numerous 
observers  have  called  attention  to  the  importance  of  tubercu- 
losis, not  only  as  a  causative  factor  in  polyneuritis,  but  also 
as  giving  rise  to  mental  symptoms  similar  to  those  just  de- 
scribed. Diabetes  and  various  disturbances  in  the  functions 
of  the  kidney  and  liver  are  also  known  to  be  associated  with 
a  similar  group  of  symptoms.  The  work  of  Klippel,  Ballet, 
Gilbert,  and  others  has  added  particular  emphasis  to  the  im- 
portance of  hepatic  insufficiency  as  a  factor  in  the  etiology  of 
similar  conditions. 


28  Serge  Soukhanoff  and  Andre  Boutenko :     A  Study  of  Korsakow's 
Disease.    Journ.  of  Ment.  Pathol.,  1903,  vol.  iv.  pp.  1-33. 

29  Miller,  Harry  W. :    Am.  Journ.  Insan.,  lx,  No.  4,  1904. 


282  PSYCHIATRY 

Differential  Diagnosis. — It  is  often  impossible  in  cases 
where  there  is  a  marked  alcoholic  history  to  distinguish  this 
condition  from  the  more  protracted  forms  of  delirium  tremens, 
but  sufficient  has  already  been  said  to  indicate  the  differences 
in  the  clinical  picture  between  these  and  the  typical  cases  of 
alcoholic  delirium.  As  many  of  the  cases  present  symptoms — 
such  as  impaired  tendon  reflexes,  a  diminished  or  absent  light 
reflex,  speech  disturbances,  and  others — which  suggest  general 
paresis,  the  differentiation  of  these  two  conditions  is  frequently 
beset  with  many  difficulties,  but  the  disorientation,  confusion, 
interference  with  consciousness,  more  or  less  evanescent  char- 
acter of  the  hallucinations,  and  the  typical  defects  in  memory 
are  significant.  The  disturbance  of  the  mental  faculties  in 
Korsakow's  psychosis  is  apt  to  be  more  or  less  episodic,  and 
not  steadily  progressive  as  in  dementia  paralytica.  Protracted 
remissions  and  the  apparent  cure,  with  a  disappearance  of  the 
prominent  physical  and  mental  symptoms,  speak  strongly  in 
favor  of  the  former  condition. 

The  features  that  distinguish  it  from  manic-depressive  in- 
sanity and  functional  psychoses  are,  as  a  rule,  fairly  character- 
istic, as  in  Korsakow's  syndrome  there  is  a  greater  interference 
with  consciousness,  a  more  specific  defect  in  memory,  greater 
confusion,  and  more  marked  physical  symptoms.  An  exami- 
nation of  the  cerebrospinal  fluid  often  gives  negative  results, 
but  in  certain  instances,  particularly  where  there  was  consid- 
erable disturbance  in  the  functions  of  the  liver,  the  fluid  was 
decidedly  colored  and  in  cases  reported  by  Castaigne  and  Gil- 
bert biliary  pigments  were  found  to  be  present. 

Treatment. — The  treatment  of  these  cases  is  largely  symp- 
tomatic. As  soon  as  the  diagnosis  is  made,  the  patient  should 
be  at  once  isolated  and  kept  in  bed.  The  diet  should  be  restricted 
to  milk  or  other  liquid  nourishment.  If  the  neuritic  complica- 
tions are  marked,  they  may  be  combated  by  the  use  of  ice-bags 
or  hot  applications,  the  physician  being  guided  by  the  comfort 
of  the  patient.  If  these  measures  do  not  relieve  the  pains,  the 
administration  of  bromides  or  chloral  or  injections  of  mor- 
phin  may  be  resorted  to.     The  warm  packs  and  continuous 


KORSAKOW'S    SYNDROME  283 

bath  frequently  give  most  satisfactory  results  in  relieving 
symptoms.  Great  care  must  be  taken  to  see  that  the  bowels 
are  kept  well  regulated  and  the  urine  should  be  carefully  ex- 
amined and  any  evidence  of  beginning  nephritic  complications 
should  be  watched  for.  In  the  asthenic  types  of  the  disease  it 
is  necessary  to  resort  to  stimulation  and  forced  feeding.  Alco- 
hol, caffein,  or  strychnin  may  be  administered  according  to  indi- 
cations. During  the  period  of  convalescence  the  patient  should 
be  kept  as  much  as  possible  in  the  open  air,  and  even  during 
the  height  of  the  disease,  if  he  is  reasonably  quiet,  his  bed 
should  be  moved  out  on  the  porch.  All  forms  of  physical  or 
mental  exertion  should  be  carefully  avoided  during  convales- 
cence. As  soon  as  the  mental  condition  of  the  patient  permits, 
massage  may  be  given.  After  he  is  well  enough  to  be  dis- 
charged from  the  hospital,  the  patient  should  be  strongly  urged 
to  take  a  prolonged  vacation.  A  sea-voyage,  or  a  residence  in 
a  locality  where  the  climate  is  not  too  stimulating,  or  subject 
to  too  great  variations  in  temperature,  will  generally  do  much 
towards  preventing  a  relapse  and  strengthening  the  physical 
and  mental  powers. 

Pathology. — Where  lesions  in  the  peripheral  nerves  have 
been  present,  we  find  the  histological  conditions  which  belong 
to  a  neuritis.  According  to  Gombault,  the  primary  lesions 
consist  in  a  segmental  periaxial  neuritis.  Parenchymatous 
changes — multiplication  of  the  nuclei,  swelling  of  the  proto- 
plasm, fragmentation,  degeneration  of  the  myelin — have  been 
reported  by  numerous  observers.  For  a  more  detailed  descrip- 
tion of  these  the  reader  is  referred  to  the  various  monographs 
upon  the  subject.  In  some  cases  the  membranes,  especially  the 
dura,  are  markedly  affected.  A  great  variety  of  changes  have 
been  described  as  occurring  in  the  cerebral  cortex,  basal  ganglia, 
and  cerebellum.  In  some  instances  in  the  cortical  cells  there  is 
a  peripheral  chromatolysis,  but  in  most  of  the  larger  cells  there 
seems  to  be  a  tendency  towards  a  central  disintegration  of  the 
Nissl  bodies ;  in  fact,  both  of  these  changes  are  almost  always 
found.  In  the  more  chronic  cases  there  are  alterations  in  the 
neuroglia.      In  the  more  acute  forms,  those  which  simulate 


284  PSYCHIATRY 

general  paresis,  there  may  be  evidence  of  mitosis  in  the  nuclei, 
with  swollen  cell  bodies,  but,  as  a  rule,  the  changes  are  more 
chronic  in  character  and  are  largely  restricted  to  an  increase 
of  the  neuroglia  fibres.  There  may  be  some  disappearance  of 
the  fibres  in  the  cortex,  particularly  of  those  in  the  tangential 
layer,  but  this  is  not  nearly  as  marked  as  in  general  paresis 
and  other  psychoses.  In  addition  to  the  changes  in  the  cen- 
tral nervous  system,  lesions  occur  in  nearly  all  the  internal 
organs,  so  that  the  general  picture  of  the  pathological  changes 
strengthens  the  view  derived  from  clinical  observation  that 
the  symptoms  are  a  result  of  a  general  intoxication. 


CHAPTER    XI 

PSYCHOSES    THE    RESULT    OF    CHRONIC    INTOXICATIONS 

Various  substances,  after  being  taken  into  the  system  for 
a  considerable  length  of  time,  are  apt  to  bring  about  a  chronic 
poisoning  or  intoxication,  which  manifests  itself  in  somatic  or 
less  often  in  psychical  disturbances.  Occasionally,  however, 
we  meet  with  instances  in  which  the  ordinary  bodily  functions 
do  not  suffer  any  marked  disturbance,  while  the  central  nervous 
system  seems  to  bear  the  brunt  of  the  degenerative  process.  In 
a  large  percentage  of  the  cases  that  come  under  the  care  of  the 
alienist  the  abuse  of  alcohol  has  been  the  main  etiological  fac- 
tor. Hence  in  view  of  its  great  frequency  and  importance  alco- 
holism will  be  discussed  somewhat  at  length,  while  the  re- 
mainder of  the  toxic  substances  which  sometimes  cause  psychi- 
cal disorders  will  be  dealt  with  much  more  briefly. 

ALCOHOLISM.1 

General  Considerations. — The  effect  of  alcohol  upon 
the  functions  of  the  central  nervous  system  is  not  always 
constant,  for  not  only  are  there  individual  idiosyncrasies,  but 
at  different  times  in  the  same  person  the  reactions  are  subject 
to  considerable  variations.  Although  some  discrepancy  still 
exists  regarding  the  results  of  recorded  observations  after  the 
ingestion  of  small  amounts,  there  is  a  marked  degree  of  una- 
nimity in  regard  to  the  symptoms  produced  by  large  doses.2 


1  Hirt,  Edward :  Der  Einfluss  des  Alkohols  auf  das  Nerven-  und 
Seelen-leben.,  Miinchen,  1904.  Abderhalden,  E. :  Bibliographie  der  gesam- 
ten  wissenschaftlichen  Literatur  iiber  den  Alcohol  u.  den  Alcoholismus. 
Berlin,  Wien,  1904. 

2  Kraepelin :  Ueber  die  Beeinflussung  einfacher  psychischer  Vorgange 
durch  einige  Arzneimittel,  1892. 

285 


286  PSYCHIATRY 

Excellent  reviews  of  the  whole  subject  are  given  by  Hoppe  3 
and  Abel.4 

The  facts  obtained  from  experimental  work  tend  to  con- 
firm clinical  experience  regarding  the  effects  of  this  drug  when 
taken  in  fairly  large  quantities.  At  first  there  is  a  limitation 
of  the  intellectual  activity,  with  an  increased  tendency  to  motor 
restlessness.  The  earlier  mental  symptoms  may  be  said  to 
consist  in  a  characteristic  disorganization  of  thought,  with  a 
more  or  less  complete  loss  of  the  power  to  focus  the  attention. 
These  symptoms  depend  in  a  measure  upon  diminished  inhibi- 
tion, so  that  every  new  sensory  stimulus,  instead  of  being  re- 
pressed, receives  more  than  its  due  valuation,  a  fact  that  be- 
comes apparent  in  the  illogical  and  foolish  conversation  so  fre- 
quently noted  in  alcoholics.  The  inclination  shown  by  patients 
who  are  under  the  influence  of  alcohol  to  translate  all  sensory 
impressions  and  ideas  into  immediate  action  is  a  form  of  psy- 
chomotor excitement  that  may  occasionally  be  limited  to  the 
speech-centres,  but  more  frequently  is  general.  All  muscular 
movements  are  in  a  measure  incoordinated,  and  to  a  certain 
degree  involuntary.  Motives  for  speech  and  action  are  fre- 
quently replaced  by  impulses  of  a  temporary  and  evanescent 
character.  The  attention  may  be  easily  gained,  but  is,  as  a 
rule,  maintained  with  difficulty.  Although  the  views  enter- 
tained in  regard  to  the  action  of  small  doses  of  alcohol  upon 
the  form  and  persistence  of  voluntary  muscular  movements 
are  conflicting,  this  does  not  hold  true  for  the  effects  of  large 
amounts.  Clinicians  generally  accept  Kraepelin's  affirmation 
that  severe  muscular  effort  is  made  more  difficult  and  does 
not  become  easier  after  the  administration  of  alcohol.  Frey's 
experiments  (1896),  which  seemed  to  show  that  following 
small  doses  (thirty  grammes  of  whiskey)  the  capacity  of  the 


8  Hoppe :  Neuere  Arbeiten  ueber  Alkoholismus.  Centralbl.  f.  Ner- 
venheilk.  u.  Psych.,  November  15,  1902,  Nr.  154,  xxv.  Jahrgang,  S.  681. 

*  Abel :  A  Critical  Review  of  the  Pharmacological  Action  of  Ethyl 
Alcohol,  with  a  Statement  of  the  Relative  Toxicity  of  the  Constituents  of 
Alcoholic  Beverages.  Physiological  Aspects  of  the  Liquor  Problem,  vol. 
ii,  1903- 


ALCOHOLISM  287 

non-fatigued  muscle  to  react  was  decreased,  while  that  of  the 
fatigued  muscle  was  increased,  have  not  been  generally  con- 
firmed. Oseretzkowski  and  Gluck  maintain  that  after  doses 
of  from  fifteen  to  fifty  grammes  of  absolute  alcohol  there  is 
in  general  a  slight  but  temporary  increase  of  the  functional 
capacity  of  the  muscle;  but  this  apparent  increase  is  attrib- 
uted by  Kraepelin  merely  to  the  disappearance  of  normal  in- 
hibition. More  recent  investigations  seem  to  indicate  that  the 
effect  of  alcohol  is  more  deleterious  to  the  fatigued  than  to 
the  non-fatigued  muscle.  At  all  events,  there  is  little  or  no 
evidence  to  prove  that  alcohol  in  small  doses  does  not  in- 
crease the  dynamic  power  of  the  muscle  in  single  spasmodic 
efforts.5 

.  Regarding  the  action  of  alcohol  upon  the  psychic  activ- 
ities there  is  still  some  discrepancy  among  observers.  It  may 
be  said,  however,  that  the  higher  the  intellectual  processes 
undertaken  by  a  person  who  has  been  given  a  certain  amount 
of  alcohol  the  more  apparent  does  the  immediate  effect  of  the 
dose  become.  In  all  cases  there  is  a  disturbance  in  the  atten- 
tion. Although  the  results  so  far  obtained  in  the  psychological 
laboratories  are  of  great  interest  in  this  connection,  they  have 
not  been  sufficiently  numerous  to  permit  of  any  wide  generali- 
zations concerning  the  clinical  effects  of  comparatively  small 
doses  of  alcohol.  As  has  already  been  stated,  the  individual 
reaction  to  the  effects  of  the  drug  varies  within  wide  limits. 
In  many  forms  of  mental  disease  intolerance  for  alcohol  is  an 
early  symptom.  This  is  particularly  noticeable  in  cases  of 
epilepsy,  in  neurasthenia,  and  in  hysterical  individuals,  as  well 
as  in  persons  who  have  been  subjected  to  severe  trauma.  Fol- 
lowing a  blow  upon  the  head  patients  may  develop  in  a  com- 
paratively short  time  a  very  marked  degree  of  intolerance  to 
the  drug.  This  symptom  is  particularly  noticeable  in  the  early 
stages  of  paresis  as  well  as  in  certain  cases  of  dementia  praecox 

5  Chaveau :  La  production  du  travail  musculaire  utilise-t-elle  comme 
potentiel  energique  l'alcool  substitue  a  une  partie  de  la  ration  alimen- 
taire  ?  Compt.  rend.,  t.  132,  No.  2 ;  and  Alcool  et  travail  musculaire. 
Academie  des  Sciences,  21  Janv.,  1901. 


288  PSYCHIATRY 

and  arteriosclerosis.  The  importance  from  a  practical  stand- 
point of  determining  the  existence  in  an  individual  of  an 
abnormal  intolerance  for  alcohol  is  not  only  of  clinical  but  also 
of  forensic  importance.  In  the  courts  a  distinction  is  frequently- 
made  between  what  may  be  termed  ordinary  intoxication  and 
states  which  are  supposed  to  be  distinctly  pathological.  Such 
a  discrimination,  however,  is  as  impracticable  as  it  is  unscien- 
tific. 

The  question  is  frequently  asked :  How  far  are  the  voli- 
tional powers  of  the  individual  diminished  by  the  use  of  alco- 
hol? and,  further,  if  volition  is  impaired,  to  what  degree  does 
the  affected  individual  become  the  subject  of  uncontrollable  im- 
pulses? In  the  milder  degrees  of  intoxication  it  is  frequently 
necessary  to  decide  how  far  memory  is  affected,  so  as  to  de- 
termine whether  certain  acts  committed  during  a  given  period 
may  or  may  not  have  been  remembered.  It  is  generally  ad- 
mitted that  alcohol,  particularly  in  large  doses,  may  produce 
marked  disturbances  in  the  field  of  consciousness,  and  that 
certain  acts  or  events  that  have  transpired  during  these  lapses 
may  be  either  completely  forgotten  or  remembered  only  in 
part  by  the  patient.  Not  infrequently  persons  who  are  addicted 
to  the  excessive  use  of  alcohol  give  evidence  of  consider- 
able intellectual  activity  without  subsequently  retaining  in 
memory  the  slightest  trace  of  what  has  transpired  during  a 
given  period  of  time.  In  some  individuals  the  physical  dis- 
turbances associated  with  this  degree  of  intoxication  are 
marked,  while  in  others  they  are  almost  entirely  absent.  In 
degenerates,  during  the  period  of  intoxication  the  motor  dis- 
turbances, as  exhibited  in  speech  and  gait,  may  not  be  greatly 
exaggerated.6  During  a  period  of  intoxication,  especially 
during  the  prodromal  and  middle  stage,  the  knee-jerks  are 
increased,  while  later  they  are  diminished.  Gudden  7  affirms 
that  in  more  than  half  of  the  intoxicated  persons  who  were 

6  Forel  in  Kolle  :    Gerichtlich-psychiatrische  Gutachten.     Stuttgart,  1899, 
S.  216. 

7  Gudden,    Hans :     Ueber    die    Pupillenreaktion    bei    Rauschzustanden 
und  ihre  forens.  Bedeutung.     Neurol.  Centralbl.,  1900,  Nr.  23. 


ALCOHOLISM  289 

admitted  to  the  psychiatrical  division  of  the  General  Hospital 
in  Munich,  during  the  period  of  exaltation,  there  was  either 
a  marked  impairment  or  a  complete  absence  of  the  light  reflex. 
This  phenomenon  disappeared  after  the  patients  had  slept  off 
the  effects  of  the  intoxication.  In  some  individuals,  in  whom 
antecedent  to  the  stage  of  intoxication  there  was  a  certain 
degree  of  mental  impairment,  diminution  in  the  light  reflex 
persisted  for  several  hours  after  the  individual  had  awakened 
from  sleep.  It  is  important  to  note  that  a  temporary  impair- 
ment of  the  light  reflex  may  occur  during  periods  of  prolonged 
intoxication,  whereas  after  a  period  of  abstinence  this  symptom 
disappears. 

Various  forms  of  sensory  paralysis  may  occur  during  a 
period  of  intoxication,  and  these  are  accompanied  by  a  nar- 
rowing of  the  field  of  consciousness  with  amnesia.  None  of 
the  physical  symptoms  can  be  considered  pathognomonic.8 

Cases  of  intoxication  in  which  there  are  extreme  motor 
restlessness  and  mental  confusion,  followed  by  a  more  or  less 
sudden  cessation  of  the  symptoms  with  a  tendency  to  sleep  for 
several  hours,  may  in  a  measure  be  considered  characteristic 
of  a  degree  of  intoxication  that  is  usually  accompanied  by 
considerable  mental  aberration.  It  is  important  from  a  foren- 
sic stand-point  to  bear  in  mind  the  fact  that  mere  intolerance 
to  alcohol  is  not  sufficient  evidence  of  mental  disease  to  justify 
the  generalization  that  if  this  condition  exists  the  acts  of  an 
individual  are  necessarily  beyond  volitional  control.  The  dis- 
turbances in  consciousness  due  to  the  effects  of  alcohol  have 
been  the  subject  of  considerable  investigation.  Two  groups 
of  cases  essentially  different  from  the  ordinary  form  of  intoxi- 
cation may  be  separated :  ( 1 )  those  in  which  the  character 
and  duration  of  the  symptoms  are  merely  those  of  the  ordinary 
drunken  person,  but  increased  in  intensity  and  duration;  (2) 
cases,  generally  occurring  in  eccentric  individuals  or  in  degen- 


8  Cramer :  Ueber  die  forensische  Bedeutung  des  normalen  und  path- 
ologischen  Rausches.  Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  xiii,  Jan., 
1903,  H.  1,  S.  36. 

IQ 


290  PSYCHIATRY 

erates,  in  which  emotional  instability,  insomnia,  and  amnesia 
develop.  In  some  instances  a  period  of  maniacal  excitement 
may  be  added  to  the  other  symptoms.  A  transitory  delirious 
state  may  form  the  connecting  link  between  intoxication  and 
a  well-developed  psychosis.  Somnambulism  and  convulsive 
seizures  are  characteristic  of  other  forms.  The  transitory 
mental  disturbances  frequently  observed  during  periods  of 
intoxication  have  also  been  made  the  subject  of  special  inves- 
tigation by  Moeli.9  This  investigator  affirms  that  cases  occur 
in  which  the  acts  executed  during  the  disturbances  in  the  field 
of  consciousness  caused  by  the  alcohol  are  prompted  by  ideas 
which  have  already  existed  for  some  time.  For  example,  an 
individual  who  for  many  years  had  been  in  comparatively  poor 
physical  health,  and  later  had  been  subject  to  vague  suspicions 
regarding  his  wife's  fidelity,  during  a  period  of  intoxication 
became  so  suspicious  and  enraged  as  to  attack  and  seriously 
injure  his  wife.  Not  only  was  no  memory  of  the  act  retained, 
but  there  was  no  recollection  of  any  event  that  had  transpired 
during  the  period  of  intoxication. 

Cases  of  individuals  who  have  shown  none  of  the  signs 
of  epilepsy,  but  who  have  committed  crimes  the  sole  motive 
for  which  has  developed  only  just  prior  to  the  acute  change 
in  the  content  of  consciousness,  are  not  uncommon.  Thus, 
for  example,  a  certain  man  shot  a  woman.  There  was  no 
recollection  of  the  act,  although  the  patient  remembered  dis- 
tinctly having  met  her,  but  on  the  following  day,  after  the 
effects  of  the  intoxication  had  subsided,  he  was  able  to  recall 
some  disconnected  events  that  had  occurred  during  the  period 
of  temporary  abolition  of  consciousness.  This,  as  well  as 
similar  cases,  in  many  respects  suggest  an  epileptiform  attack. 
The  stupor  and  disorientation  characteristic  of  many  cases 
of  epilepsy  are  absent.     Partial  or  complete  amnesia,  however, 


8  Ueber  die  voriibergehenden  Zustande  abnormen  Bewusstseins  infolge 
von  Alkoholvergiftung  u.  iiber  deren  forensische  Bedeutung.  Allg.  Ztschr. 
f.  Psych.,  1900,  Bd.  57,  H.  2  und  3. 


DELIRIUM    TREMENS  291 

may  occur  in  both  instances.  Bregmann10  believes  that  the 
most  dangerous  form  of  alcoholism  occurs  in  individuals  whose 
nervous  systems  present  a  considerable  power  of  resistance  for 
the  toxic  action  of  the  drug,  and,  instead  of  the  development  of 
multiple  neuritis,  delirium  tremens  or  other  psychoses,  only 
lapses  in  morality  and  intellection  are  noted. 

Confusion  still  exists  in  regard  to  the  identity  of  many  of 
the  symptom-complexes  which  are  classed  as  alcoholic  psy- 
choses. At  present  the  clinical  forms  of  the  disease  may  be 
considered  under  the  following  heads : 

(1)  Delirium  Tremens. — This  condition  is  character- 
ized by  an  acute  course  and  by  a  group  of  symptoms  essentially 
different  in  many  respects  from  those  occurring  in  other  de- 
lirious states.  There  is  an  impairment  of  the  associational 
activities  of  the  brain,  with  accompanying  fallacious  sense  per- 
ceptions, motor  restlessness  of  varying  degree,  and  a  tremor 
which  is  in  a  measure  characteristic.  During  the  prodromal 
period  certain  initial  symptoms  are  often  observable  several 
days  before  the  outbreak  of  the  delirium.  The  physical  mani- 
festations of  chronic  alcoholism,  such  as  nausea  or  vomiting, 
are  frequently  present.  As  a  rule,  some  slight  motor  restless- 
ness, more  pronounced  at  night,  is  noted,  while  during  the  day 
the  patient  may  complain  of  feeling  ill  at  ease,  of  being  excess- 
ively nervous,  and  show  himself  abnormally  responsive  to 
external  stimulation.  In  some  cases  only  a  vague  feeling  of 
apprehension  is  present  or  there  may  be  an  ill-defined  fore- 
boding of  some  unpleasant  occurrence.  In  the  majority  of 
cases  the  visual  stimuli  are  followed  by  more  intense  reactions 
and  are  much  more  apt  to  give  rise  to  anxious  states  than 
those  affecting  the  auditory  mechanism.  If  the  patients  sleep 
at  all  at  night,  they  are  very  apt  to  be  excited  and  extremely 
restless,  thrashing  about  in  their  beds,  talking  in  their  sleep, 
and  sometimes  being  victims  to  somnambulism.  In  place  of 
"the  feeling  of    depression   during  the  prodromal   period,   at 


10  Die  Behandlung  der  Trinker  u.  der  Kampf  mit  dem  Alkoholismus. 
Sdrowie,  1902. 


292  PSYCHIATRY 

times  a  slight  hypomaniacal  condition  may  develop,  that  is 
apt  to  persist  and  continue  during  the  height  of  the  delirium. 
The  transition  from  the  prodromal  to  the  second  stage 
of  the  disorder  can  not  always  be  sharply  differentiated.  In 
most  of  the  cases  the  above-mentioned  symptoms  precede  the 
acute  outbreak  by  only  a  few  days,  or  they  may  develop  more 
gradually,  culminating  in  the  delirious  condition  only  at  the 
end  of  two  or  three  weeks.  As  a  rule,  the  restlessness,  the  dis- 
turbances of  consciousness,  and  anomalies  of  sensation  become 
greatly  accentuated  as  soon  as  the  second  or  delirious  stage 
begins.  During  this  period  the  disturbances  of  sensation  are 
in  a  measure  characteristic.  The  patients,  as  a  rule,  suffer 
from  visual,  haptic,  and  auditory  hallucinations.  The  occur- 
rence of  the  last-named  variety  always  indicates  a  graver  prog- 
nosis. Although  the  bizarre,  grotesque,  or  fantastic  character 
of  these  disturbances  is  of  great  importance,  the  nature  of 
the  hallucinations  may  to  some  extent  be  determined  by  the 
daily  life  of  the  patient  prior  to  the  outbreak  of  the  disease; 
the  coachman  drives  his  horses,  the  butcher  is  busy  in  his 
shop,  the  artist  paints  imaginary  pictures.  On  the  other  hand, 
his  immediate  environment  may  exert  little  influence  in  this 
regard;  the  patient,  while  lying  in  bed  in  a  state  of  marked 
delirium,  although  restrained  by  the  camisole,  may  consider 
himself  at  home  and  carry  on  conversations  with  imaginary 
friends.  Any  stimulus  of  sufficient  strength  impinging  upon 
the  cerebral  cortex  serves  to  awaken  a  chain  of  memory  pic- 
tures and  suggests  situations  or  events  in  his  former  daily 
life.  Not  uncommonly  there  is  a  tendency  on  the  part  of  the 
patients  to  associate  their  hallucinations  with  forms  of  move- 
ment,— they  say  they  are  flying  in  the  air,  swimming,  rising 
in  water,  or  the  like;  but,  according  to  Liepmann,  these  will 
disappear  if  the  sufferers  are  kept  absolutely  quiet.  The  vis- 
ual hallucinations  may  be  colored  or  may  be  shadow-like 
visions.  As  a  rule,  the  forms  of  rats,  snakes,  insects,  fish,  or 
other  animals  are  prominent  features.  Not  infrequently  the 
visual  hallucinations  are  recognized  as  unreal.  The  belief  in 
the  subjectivity  of  these  phenomena  varies  during  the  height 


DELIRIUM    TREMENS 


293 


of  the  delirium.  Very  commonly  the  anaesthesias,  hyperes- 
thesias, and  paresthesias  are  attributed  to  unseen  agencies, — 
to  spirits  or  devils. 

The  cutaneous  hallucinations  are  of  various  forms,  and 
movement  is  again  a  prominent  feature  of  them.  Formication 
— the  sensation  as  of  insects  crawling  over  the  limbs,  body, 
etc. — is  often  complained  of.  The  haptic  hallucinations  are 
frequently  referred  to  the  hands,  the  face,  or  the  inside  of  the 
mouth.  The  sensory  disturbances  may  suggest  to  the  patient 
the  use  of  familiar  objects.  Thus,  smokers  affirm  that  they 
have  a  cigar  or  pipe  between  their  lips.  Auditory  hallucina- 
tions, although  less  prominent,  vary  greatly  in  complexity, 
from  simple  elementary  akoasmata  to  the  more  complicated 
sounds  of  voices  engaged  in  conversation.  Bonhoeffer  refers 
to  the  fact  that  auditory  hallucinations  characterized  by  a 
monotone  are  never  observed  in  delirious  patients,  but,  as  a 
rule,  possess  a  definite  rhythmic  character.  Hallucinations  of 
taste  have  been  reported  by  some  observers. 

As  has  already  been  mentioned  in  the  chapter  dealing  with 
disturbances  of  sensation,  clinicians  are  almost  unanimous  in 
emphasizing  the  importance  of  the  role  played  by  definite 
lesions  in  the  peripheral  nerves  in  determining  the  occurrence 
of  hallucinations  and  illusions.  Magnan,  Galezowsky,  Rose, 
Kruckenberg,  and  others  have  affirmed  that  elementary  dis- 
turbances in  perception  occur  during  the  delirium,  but  the 
difficulties  that  beset  the  solution  of  this  question  are  very 
great.  In  many  cases  of  delirium  it  is  impossible  definitely  to 
prove  or  disprove  the  existence  of  disturbances  in  the  cutaneous 
sensibility.  Bonhoeffer  believes  that  hearing  is  not  impaired; 
that  in  most  of  the  cases  the  anaesthesias  are  of  psychic  origin, 
due  to  the  deflection  of  the  patient's  attention;  and  less  fre- 
quently are  the  result  of  lesions  in  the  peripheral  nerves. 

These  investigations  of  Bonhoeffer  do  not  corroborate 
those  of  Magnan,  which  tended  to  prove  that  amblyopia  fre- 
quently occurs  during  the  delirious  process.  Kruckenberg  be- 
lieves that  there  is  often  a  narrowing  in  the  field  of  vision,  an 
observation,  however,  which  needs  further  confirmation.     Bon- 


294 


PSYCHIATRY 


hoeffer  affirms  that  as  yet  there  exists  little  evidence  which 
is  indicative  of  the  existence  of  great  impairment  in  the  sharp- 
ness of  perception.  If  the  latter's  observations  are  correct,  it 
would  seem  improbable  that  the  localization  of  the  hallucinations 
is  determined  solely  by  lesions  occurring  in  the  peripheral 
organs.  The  attention  during  the  height  of  the  delirium  is  seri- 
ously impaired,  but  it  not  infrequently  happens  that  for  a  very 
short  period  the  power  of  focussing  the  mental  faculties  upon 
a  given  object  is  surprisingly  great.  The  disturbances  in  speech 
are  often  well  marked.  If  a  patient  is  made  to  read  aloud, 
the  psychical  defects  frequently  become  much  more  promi- 
nent. Paralexia  is  not  uncommon.  Slight  disturbances  in 
the  ocular  muscles  may  increase  the  difficulty  in  reading,  but 
when  this  is  the  case,  with  one  eye  covered  the  patient  is  able 
to  proceed  with  greater  rapidity  and  with  fewer  mistakes.  The 
rapid  flow  of  ideas  which  frequently  occurs  is  in  a  measure 
pathognomonic.  The  patients  ramble  along  in  their  conver- 
sation without  any  apparent  definite  aim  in  view.  Each  new 
impulse,  either  intra-  or  extra-organic,  suggests  a  new  idea, 
which  is  rapidly  replaced  by  another.  This  symptom  has  been 
referred  to  as  a  sensory  flight  of  ideas.  Kraepelin  and  Aschaf- 
fenburg  have  pointed  out  that  external  stimuli  play  a  very 
important  role  in  determining  the  character  of  the  deliria  and 
that  the  tendency  to  rhyme  and  to  form  sound  associations  is 
usually  well  marked.  The  suggestibility  of  the  patients,  as 
would  be  expected,  is  very  great,  being  generally  more  pro- 
nounced in  this  than  in  any  other  psychosis.  The  memory 
for  occurrences  long  antedating  the  onset  of  the  delirium  may 
be  relatively  intact,  while  for  the  more  immediate  past  it 
is  often  a  blank.  The  time  sense  is  seriously  disorganized. 
The  tendency  to  confabulate  is  decided,  but  this  symptom  is 
also  common  to  other  psychoses  in  which  the  attention  is  greatly 
impaired.  The  loss  of  ^orientation,  which  is  frequently  pro- 
nounced, in  a  measure  depends  upon  the  patient's  falsification 
of  the  representation  of  the  external  world  as  well  as  upon  the 
protean  and  evanescent  character  of  the  sensory  impressions; 
but,  as  Wernicke  has  suggested,  this  is  not  the  sole  cause  of 


DELIRIUM    TREMENS 


295 


the  disorientation.  In  nearly  all  cases  the  dissociation  of 
thought  is  so  great  that  the  judgment  becomes  very  defective, 
although  now  and  again  a  patient,  even  during  the  height  of 
the  delirium,  will  attempt  to  explain  and  correlate  the  isolated 
and  irrelevant  ideas  which  seem  to  spring  into  consciousness, 
thus  showing  the  existence  of  a  suggestion  of  coordination  in 
the  thought  processes.  The  sej  unction  of  the  personality 
varies  in  degree.  Wernicke  holds  that  the  falsifications  of 
the  external  world,  or  allopsychic  consciousness,  are  very 
great,  while  the  preservation  of  the  autopsychic  is  equally 
distinctive. 

In  cases  in  which  megalomania  is  present,  there  is  reason 
for  suspecting  the  existence  of  an  incipient  paresis  or  some 
other  form  of  psychosis  as  a  complication.  The  emotional 
disturbances  in  these  patients  are  essentially  characteristic. 
The  anxiety,  which  is  frequently  intense,  may  be  localized 
in  the  chest,  but,  as  a  rule,  it  is  much  more  general  in  char- 
acter and  dominates  all  the  actions  of  the  patient.  The  emo- 
tional disturbance  is  apt  to  fluctuate  markedly,  particularly 
in  the  earlier  stages ;  it  often  reaches  such  a  degree  that  any- 
thing approaching  to  a  thorough  examination  is  not  possible, 
although  not  uncommonly  the  patient  may  be  temporarily 
pacified.  On  the  other  hand,  in  the  later  stage  of  the  delir- 
ium a  well-marked  complacency  may  develop.  General  psycho- 
motor restlessness  is  nearly  always  a  prominent  symptom, 
but  at  times  does  not  affect  the  speech-centres,  so  that  the  pa- 
tients may  not  be  unduly  garrulous,  and  the  field  of  attention 
seems  to  be  greatly  narrowed.  In  some  instances  a  patient 
will  sit  for  hours  without  uttering  a  word;  while  in  others 
the  speech  compulsion  is  quite  as  marked  as  the  general  motor 
restlessness.  The  tremor — which  gives  its  name  to  the  de- 
lirium— appears,  as  a  rule,  in  the  extremities,  tongue,  and  not 
infrequently  in  the  facial  muscles,  particularly  those  connected 
with  speech.  It  may  become  so  intense  that  the  patient  is 
hardly  able  to  stand  or  to  give  audible  expression  to  his 
thoughts,  and  under  these  conditions  the  speech  disturbance 
is  readily  recognized  as  a  purely  motor  disorder  and  thus  may 
be  easily  distinguished  from  that  of  general  paresis. 


296  PSYCHIATRY 

The  period  of  the  delirium  is  nearly  always  associated 
with  some  elevation  of  temperature,  the  origin  of  which  has 
not  been  satisfactorily  explained,  although  it  may  be  said  that 
high  fever  generally  indicates  the  existence  of  some  compli- 
cation. The  pulse  varies  during  the  height  of  the  delirium; 
it  may  be  almost  imperceptible  and  so  rapid  as  to  be  counted 
with  difficulty.  An  acute  cardiac  dilatation  may  develop  dur- 
ing this  stage. 

During  the  prodromal  period,  when  the  symptoms  are 
vague  and  indefinite, — somewhat  resembling  those  occurring 
in  the  initial  stage  of  any  acute  infectious  disease, — there  is 
at  first  active  skin  hyperemia,  which  lasts  from  eight  to  ten 
hours  and  is  then  followed  by  a  contraction  of  the  superficial 
blood-vessels.  The  blood-pressure  also  increases  after  the  ini- 
tial hypersemic  stage  has  passed,  and  is  said  to  remain  high 
as  long  as  the  delirious  symptoms  persist.  Following  the 
rapid  pulse  of  the  acute  stage,  there  is  a  period  during  which 
bradycardia  is  pronounced,  the  rate  falling  to  50  beats  or  less 
per  minute.  According  to  Dollken,11  this  symptom  is  refer- 
able to  the  exhaustion. 

The  other  physical  symptoms  are  not  essentially  different 
from  those  which  occur  during  any  form  of  delirium.  The 
urine  shows  no  specific  changes.  Albumin  and  casts  are  not 
infrequently  found.  The  blood  examinations  are  practically 
negative,  although  during  the  period  of  the  most  intense  ex- 
citement Elsholz  was  unable  to  find  any  eosinophiles.  For- 
merly clinicians  regarded  the  symptoms  as  being  merely  de- 
pendent upon  hyperexcitation  of  the  cerebral  cortex,  but 
Wernicke  and  others  have  recently  called  attention  to  the  fact 
that  actual  psychic  paralyses  exist. 

The  course  of  the  disease  varies  in  different  cases.     The 
prodromal  period,   although  practically  never   absent,    is   re 
duced  to  a  minimum  in  the  cases  complicating  acute  disease. 
For  example,  a  certain  man  who  for  years  had  been  a  hard 


11  Die   korperlichen    Erscheinungen    des    Delirium    tremens.      Leipzig. 
)i. 


DELIRIUM    TREMENS  297 

drinker,  while  at  work  in  a  factory  suffered  a  severe  wrench 
of  his  arm,  necessitating  removal  to  a  hospital,  where  almost 
immediately  symptoms  of  delirium  tremens  developed,  al- 
though prior  to  the  injury  he  had  not  shown  any  marked 
nervous  disturbance.  In  the  so-called  abortive  forms,  the 
patient,  after  a  period  of  prolonged  anxiety,  breaks  out  into 
a  profuse  sweat,  and  after  a  few  days  the  symptoms  gradu- 
ally subside,  the  second  stage  being  absent.  In  some  instances 
the  initial  stage  is  succeeded  by  one  in  which  all,  particularly 
the  psychic,  symptoms  become  accentuated.  This  period  ends 
after  from  four  to  eight  days  in  convalescence.  In  these  cases 
the  first  or  prodromal  stage — characterized  by  nervousness, 
slight  motor  restlessness,  tremor,  sleeplessness,  etc. — is  fol- 
lowed by  the  period  in  which  most  of  the  psychical  symptoms 
attain  their  maximum,  and  then  gradually  subside  until  the 
stage  of  convalescence  is  finally  established. 

As  a  rule,  the  first  signs  of  improvement  consist  in  the 
gradual  subsidence  of  the  hallucinations  and  delusions  and  the 
disappearance  of  the  affective  disorders.  The  motor  restless- 
ness disappears ;  the  patient  now  lies  quietly  in  bed,  and  sooner 
or  later  falls  into  a  deep  sleep  which  may  persist  for  twenty- 
four  or  forty-eight  hours.  After  the  acute  symptoms  have 
completely  disappeared,  some  slight  disorientation  and  dis- 
sociation in  thought  may  persist  for  several  days.  The  pa- 
tient's actual  insight  into  his  condition  varies  considerably. 
In  some  instances  the  period  of  delirium  is  a  blank.  Other 
patients  remember  that  they  have  been  ill  and  not  infrequently 
are  able  to  recall  certain  of  the  hallucinations  from  which  they 
have  suffered. 

In  the  so-called  adynamic  form  of  the  disease,  that  is 
occasionally  met  with,  the  pulse  is  compressible  and  small,  the 
patient  is  more  or  less  stuporous,  sweats  profusely,  and  pre- 
sents a  clinical  picture  in  which  it  is  difficult  to  recognize  any 
of  the  specific  signs  of  delirium  tremens. 

The  final  outcome  of  the  majority  of  cases  is  in  recovery, 
the  mortality  in  the  uncomplicated  cases  being  3  or  4  per  cent. 
In  those  in  which  complications  exist  the  death-rate  is  much 


298  PSYCHIATRY 

higher, — from  10  to  15  per  cent.  Pneumonia  is  most  often 
responsible  for  the  fatal  ending.  In  other  instances  the  chronic 
gastro-intestinal  disturbances  become  prominent  and  greatly 
increase  the  danger  in  the  disease.  Patients  suffering  from 
delirium  tremens  are  peculiarly  susceptible  to  infection. 

Pathogenesis. — The  delirium  develops  on  the  basis  of 
chronic  alcoholism,  so  that  it  may  in  a  measure  be  regarded 
as  an  acute  exacerbation  of  a  chronic  process.  Jacobson 12 
has  studied  247  cases  of  delirium  tremens  with  a  view  of  de- 
termining certain  important  points  in  the  pathogenesis.  In 
every  instance  the  patients  were  found  to  have  presented  symp- 
toms of  chronic  alcoholism  for  periods  varying  from  one  to 
seven  years  prior  to  the  outbreak  of  the  delirium.  The  great 
majority  of  these  individuals  were  habitual  drinkers;  60  per 
cent,  partook  of  whiskey,  30  per  cent,  of  beer  and  whiskey,  and 
6  per  cent,  of  beer  alone.  In  14  cases  the  outbreak  of  the 
delirium  followed  trauma.  Elmergreen  13  and  Pritchard  14  de- 
scribe a  mild  form  of  the  disease,  seen  in  moderate  drinkers, 
and  an  exaggerated  type,  or  forme  foudroyante,  in  those  indi- 
viduals who  are  addicted  to  marked  alcoholic  excesses. 

Certain  predisposing  factors  favor  the  outbreak  of  the 
delirium.  Among  the  most  important  are  those  that  in  a 
measure  lower  the  resistance  of  the  organism, — trauma,  fever, 
particularly  pneumonia,  operations,  marked  emotional  disturb- 
ances or  excitement,  profound  anaemia,  conditions  of  life  which 
lead  to  states  of  physical  or  mental  exhaustion, — anything,  in 
fact,  that  overtaxes  the  functions  of  the  central  nervous  sys- 
tem. It  is  a  common  experience  in  general  hospitals  that 
patients  suffering  from  delirium  tremens  are  particularly  lia- 
ble to  develop  pneumonia.      Jacobson  has  affirmed  that  cer- 


12  Jacobson,  E. :  Ueber  die  Pathogenese  des  Delirium  tremens.  Allg. 
Ztschr.  f.  Psych.,  Bd.  54,  H.  1  u.  2. 

13  Elmergreen :  Delirium  Tremens  in  Moderate  Consumers  of  Alcohol, 
with  Report  of  Four  Cases.  Med.  Times,  July,  1899.  The  Delirium  Tre- 
mens in  Moderate  Drinkers.    Journ.  Am.  Med.  Assoc,  November,  1900. 

14  Pritchard :  Delirium  Tremens  in  Moderate  Consumers  of  Alcohol. 
Med.  Times,  1899,  No.  8. 


DELIRIUM   TREMENS 


299 


tain  symptoms — fever,  albuminuria,  enlarged  spleen — suggest 
the  striking  resemblance  between  delirium  tremens  and  the 
acute  infectious  diseases,  and  he  sought  to  establish  a  causal 
relationship  between  the  pneumococcus  and  the  outbreak  of 
the  delirium.  Similar  views  have  been  advocated  by  Villers,15 
who  maintained  that  in  the  majority  of  cases  of  delirium  the 
pneumococcus  was  the  factor  of  greatest  etiologic  importance. 
Hertz  has  affirmed  that  delirium  tremens  is  an  intoxication 
psychosis  due  to  the  impairment  of  the  function  of  the  kid- 
neys. In  15  cases  of  uncomplicated  delirium  tremens  Nonne16 
proved  that  the  cultures  taken  from  the  blood  were  sterile  and 
thinks  this  sufficient  reason  for  not  regarding  the  delirium  as 
the  result  of  an  infectious  process. 

The  peculiarity  characteristic  of  the  disease  is  attributable 
to  the  fact  that  the  symptoms  occur  only  in  those  who  have 
suffered  from  the  effects  of  chronic  alcoholism.  It  is  gener- 
ally held  that  the  delirium  may  develop  in  chronic  drinkers 
when  alcohol  is  suddenly  withdrawn,  but  this  view  has  recently 
been  called  into  question.  Weygandt,  while  admitting  such 
a  possibility,  maintains  that  if  they  do  occur  all  such  cases 
present  very  mild  forms  of  the  disease. 

Most  of  the  recorded  clinical  observations  of  cases  of 
delirium  tremens  have  been  made  during  the  height  of  the 
delirium.  The  periods  of  development  and  decline,  during 
which  symptoms  may  arise  that  would  furnish  important  clues 
as  to  the  pathogenesis  of  this  state,  have  not  until  recently 
been  studied  with  sufficient  accuracy. 

Delirium  tremens  is  generally  seen  in  individuals  in  the 
prime  of  life;  it  is  more  frequent  in  men  than  in  women,  but 
in  rare  instances  children  have  been  known  to  suffer  from  it. 
It  is  impossible  to  say,  even  approximately,  the  amount  of 
alcohol  which  will  give  rise  to  this  group  of  symptoms,  as 
the  individual  idiosyncrasies  are  so  varied.    As  would  be  sup- 

15  Pathogenie  et  pronostic  du  delirium  tremens.    Bulletin  de  la  soc.  de 
med.  ment.  de  Belgique,  1898,  p.  142. 

16  Allg.  Ztschr.  f.  Psych,  u.  psych. -gericht.  Medizin,  1904,  Feb.  15,  Bd. 
61,  H.  1  u.  2. 


300 


PSYCHIATRY 


posed,  the  disease  is  more  common  in  countries  in  which  whis- 
key and  brandy  are  taken  in  large  quantities  than  in  the  south- 
ern parts  of  the  globe  where  wine  is  the  chief  beverage. 

(2)  Acute  Alcoholic  Hallucinosis  (Wernicke,  Bon- 
hoeffer). — The  chief  characteristic  of  this  group  of  cases  is 
anxiety  associated  with  comparatively  mild  disturbances  in 
the  somatopsychic  and  allopsychic  fields  of  consciousness.  Fur- 
thermore, in  addition  to  hallucinations  (similar  in  character 
to  those  occurring  in  delirium  tremens),  there  can  be  noted 
a  manifest  attempt  on  the  part  of  the  patient  to  explain  and 
establish  some  sort  of  relationship  between  the  various  iso- 
lated and  incongruous  facts  existing  in  his  consciousness. 
For  this  latter  reason,  the  condition  is  referred  to  by  some 
authors  as  acute  alcoholic  paranoia. 

In  some  instances  the  intense  affective  disorders  are  ref- 
erable to  auditory  hallucinations  of  a  threatening  or  terrifying 
character.  Some  patients  affirm  that  every  person  that  enters 
the  room  has  maligned  them  or  has  attempted  to  subject  them 
to  sinister  influences,  and  not  infrequently  declare  that  the 
thoughts  of  the  individuals  who  wish  to  do  them  harm  are 
communicated  through  the  medium  of  the  air  or  by  unseen 
spirits.  The  complaint  is  not  infrequently  made  by  the  pa- 
tients that  they  can  keep  nothing  secret,  as  their  every  thought 
is  audible  to  those  about  them. 

The  history  of  the  following  case  illustrates  this  clinical 
type. 

Male,  single;  aged  36.  Had  been  accustomed  to  take  alcohol  for  a 
number  of  years  in  considerable  quantities,  and  has  also  smoked  ex- 
cessively. For  some  six  months  prior  to  admission  he  had  been  drinking 
more  heavily  and  constantly,  frequently  taking  thirty  or  forty  drinks  of 
whiskey  a  day.  For  about  six  weeks  his  friends  and  relatives  noticed  that 
he  was  becoming  very  nervous.  He  expressed  fear  of  bodily  harm,  and 
had  periods  of  combativeness  alternating  with  others  of  marked  docility. 
He  began  to  be  subject  to  optical  hallucinations,  usually  of  a  pleasant  type, 
and  to  auditory  hallucinations.  He  imagined  that  he  heard  all  sorts  of 
noises,  and  occasionally  thought  that  people  were  plotting  to  do  him  harm. 
After  his  admission  to  the  hospital  these  symptoms  persisted.  His  con- 
versation was  confused  and  irrelevant  and  he  showed  marked  disorienta- 
tion for  time  and  place.     The  anxiety  was  not  as  great  as  that  noticed  in 


ALCOHOLIC   HALLUCINOSIS 


301 


cases  of  delirium  tremens.  He  recognized  objects,  but  mistook  persons. 
He  was  able  to  do  simple  multiplication  rapidly.  At  times  he  obeyed 
orders  only  slowly,  as  if  confused,  but  at  other  times  quickly  and  intelli- 
gently. He  affirmed  that  he  had  died  eighteen  years  before  and  had  been 
dug  up  three  weeks  prior  to  his  admission  to  the  hospital.  He  said  he  had 
felt  the  snails  crawling  over  him,  and  that  he  was  "  nicely  packed  in  a 
coffin  with  straw."  He  knew  who  he  was ;  showed  little,  if  any,  dis- 
turbance in  autopsychic  consciousness ;  and  responded  correctly  to  a 
three-word  test.  After  these  symptoms  had  persisted  for  several  weeks, 
the  patient  began  to  have  periods  during  which  the  hallucinations  were  less 
marked.  Gradually,  but  at  first  for  only  brief  intervals,  he  recognized  the 
fact  that  he  had  been  ill,  and  was  extremely  nervous  and  was  willing  to 
admit  that  he  was  not  responsible  for  what  he  said  or  did.  After  such 
ameliorations  the  old  symptoms  would  return  again.  Gradually  the  lucid 
intervals  became  longer ;  his  bodily  weight  increased,  and  finally,  after 
being  under  observation  for  three  months,  he  was  discharged. 


4^ 


^T^.    ^.  ***  *%**- 


^      U^c,       JUA^r^-     *****      ^T. 


This  was  written  by  patient  during  the  period  of  acute  delirium.  Disturbances  in  the 
functions  of  the  peripheral  nerves  were  the  basis  for  the  ideas  in  regard  to  death,  burial,  and 
resurrection.    The  patient  constantly  complained  of  feeling  snails  crawling  over  his  legs. 

Although  the  majority  of  patients  make  some  attempt  to 
explain  the  hallucinations  and  delusions,  systematization  is  by 
no  means  equally  developed  in  all  cases.  States  of  anxiety  are 
frequently  a  prominent  symptom.  Sometimes  megalomania 
is  present,  but  this  is  not  characterized  by  the  exaggerated 
self-complacency  that  appears  in  paretics.  In  marked  con- 
trast to  what  is   encountered   in  cases   of  delirium  tremens, 


302 


PSYCHIATRY 


these  patients  show  relatively  little  impairment  in  connected 
thought.  There  is  less  tendency  to  reckless  confabulation,  and 
the  power  of  picking  up  and  retaining  new  impressions  is 
much  less  impaired  than  it  is  in  the  delirious  cases.  Concern- 
ing the  preservation  of  the  powers  of  orientation,  clinicians 
differ;  they  are  agreed,  however,  that  neither  space  nor  time 
sense  is  intact.  The  degree  of  impairment  varies  in  different 
cases.  The  hallucinatory  disturbances  apparently  come  and 
go.  The  patients  have  periods,  lasting  a  few  hours,  during 
which  the  voices  or  visions  become  unusually  prominent  and 
then  gradually  subside.  The  somatic  disturbances  are  the 
same  as  those  noted  in  other  forms  of  alcoholism.17 


Insight  into  his  condition  partially  regained.    Interval  of  several  weeks  had  elapsed. 

The  more  the  clinical  picture  corresponds  to  that  of  de- 
lirium tremens  the  more  favorable  is  the  prognosis.  Some 
clinicians  affirm  that  the  occurrence  of  hallucinations  other 
than  auditory  is  more  apt  to  be  associated  with  the  severer 
and  more  protracted  forms  of  the  disease;  while  those  in 
which  there  is  marked  disturbance  in  the  organic  sensations 
are  looked  upon  as  particularly  unfavorable.     It  is  not  at  all 

17  Illberg :    Der  Akute  hallucinatorische  Alkoholwahnsinn.     Festschrift 
zum  50-jahr.  Bestehen  des  Stadtkrankenhauses  zu  Dresden. 


ALCOHOLIC   HALLUCINOSIS  303 

improbable  that  some  of  the  incurable  forms  of  chronic  alco- 
holism begin  with  a  period  in  which  the  symptoms  resemble 
those  of  acute  hallucinosis. 

J*  S  J  S     J^V 

7t4C<j       *e&+-*'tsf^     yo<st-^z«-*<.        cz^f-^t-y 

Complete  insight.     Written  just  prior  to  discharge  from  hospital. 

Pathogenesis. — It  is  interesting  to  note  that,  whereas  in 
delirium  tremens  optic  and  tactile  hallucinations  are  prominent, 
in  the  acute  hallucinosis  those  of  the  acoustic  type  predominate. 
The  essential  difference  in  the  two  clinical  pictures  has  been 
referred  by  some  clinicians  to  the  individual  differences  exist- 
ing in  regard  to  the  functional  importance  of  the  auditory 
centres.  Such  an  attempted  explanation,  however,  is  unsatis- 
factory, inasmuch  as  cases  have  been  reported  in  which  delirium 


304 


PSYCHIATRY 


tremens  and  hallucinosis  have  occurred  in  the  same  individual. 
The  differential  diagnosis  in  typical  cases  is  not  difficult.  The 
alcoholic  amnesia,  the  more  or  less  sudden  occurrence  of  audi- 
tory hallucinations,  the  comparatively  slight  disturbances  in 
associated  thinking,  the  delusions  bound  together  with  more 
or  less  systematization,  are  the  essential  points  to  be  kept  in 
mind.  Although  the  clinical  picture  described  is  most  fre- 
quently associated  with  alcoholism,  it  is  not  improbable  that 
it  occasionally  occurs  in  other  diseases. 

The  prognosis  in  many  of  the  cases  is  favorable.  The 
majority  of  the  patients  recover  completely.  Relapses  are, 
however,  not  infrequent. 

The  duration  of  the  disease  varies  from  six  or  eight  weeks 
for  the  milder  cases  to  three  or  four  months  for  the  severer 
types. 

(3)  Paranoiic  and  Dementing  States. — The  para- 
noiic  states  which  develop  during  chronic  alcoholism  are  often 
divided  into  two  categories :  ( 1 )  Those  which  may  be  looked 
upon  as  sequelae  of  either  delirium  tremens  or  acute  hallucino- 
sis; and  (2)  the  so-called  primary  forms,  which  are  less  fre- 
quent and  have  a  more  unfavorable  outcome.  Raecke  18  be- 
lieves that  the  true  chronic  alcoholic  paranoiic  state  may  be  still 
further  differentiated  from  those  cases  in  which  there  are  long 
remissions  and  a  relatively  favorable  outlook.  Patients  may 
pass  through  an  attack  of  delirium  tremens  and  improve  men- 
tally and  physically  in  every  way  except  that  they  are  harassed 
by  one  or  more  persistent  delusions.  As  a  rule,  the  insane 
ideas  retain  the  same  stamp  of  grotesqueness  which  charac- 
terizes them  in  the  course  of  the  other  alcoholic  psychoses,  and 
at  the  same  time  defects  in  the  social  and  ethical  conscience 
of  the  patient  are  nearly  always  well  marked.  The  patient 
may  affirm  that  his  body  is  to  be  burned  or  that  he  has  been 
dead  and  buried.  A  few  of  the  persistent  ideas  may  be  accom- 
panied by  others  that  are  transitory  in  character.  Although 
on  superficial  examination  judgment  and  memory  seem  to  be 

18  Neurolog.  Centralbl..  1903,  Nr.  21,  Nov.  1,  S.  1032. 


PARANOIIC    STATES  305 

intact,  a  more  careful  analysis  of  the  symptoms  will  seldom 
fail  to  reveal  the  existence  of  considerable  intellectual  weak- 
ness. Some  patients  pass  directly  from  the  acute  stages  of 
delirium  tremens  or  the  acute  hallucinosis  into  the  chronic 
paranoiic  state.  Particularly  characteristic  of  the  latter  form 
of  chronic  alcoholism  are  the  ideas  of  suspiciousness  and  jeal- 
ousy, which  may  almost  be  regarded  as  specific  and  are  fre- 
quently directed  against  the  members  of  the  patient's  own 
family.  Individuals  in  this  state  affirm  that  an  attempt  is 
being  made  by  members  of  their  family  to  get  rid  of  them, — 
that,  for  example,  poison  is  introduced  into  their  food, — and 
the  parsesthesias  or  anaesthesias  to  which'  they  may  be  subject 
become  to  them  signs  of  unseen  agencies  which  are  being 
employed  for  their  torture  or  destruction.  In  a  comparatively 
large  number  of  these  cases  the  delusions  are  sexual  in  char- 
acter. V.  Krafft-Ebing  affirms  that  the  insane  ideas  of  perse- 
cution in  about  80  per  cent,  of  the  male  alcoholics  are  of  this 
character.  Not  uncommonly  there  is  an  hyperaesthesia  sexu- 
alis.  The  failure  to  satisfy  this  passion  frequently  enrages 
the  patient,  and  the  wife  is  often  accused  of  infidelity  in  its 
most  disgusting  and  revolting  forms.  As  a  rule,  these  insane 
ideas  are  accompanied  by  great  emotional  instability,  which 
often  expresses  itself  in  violent  outbreaks  of  temper,  while  in 
the  intervals  the  patient  may  be  sullen  and  morose.  The 
erotic  excitement  is  liable  to  be  most  intense  early  in  the  dis- 
ease. The  hyperaesthesia  is  followed  by  the  stage  in  which 
sexual  desire  is  partially  or  completely  absent.  Hallucinations 
only  occasionally  occur  during  this  paranoiic  stage.  The  emo- 
tional equilibrium  of  the  patients  varies.  At  times  there 
is  considerable  apathy,  or  again  mild  depression  alternates 
with  periods  of  excitement.  During  the  latter  stage  the  so- 
called  "  alcoholic  humor"  becomes  noticeable.  At  times  the 
patient  may  become  excited,  particularly  when  surrounded  by 
members  of  his  family.  If  these  individuals  are  kept  in  an 
institution  where  they  do  not  have  access  to  any  form  of  alco- 
hol, there  may  be  considerable  improvement  after  several 
months  or  a  year;    the  hallucinations  may  disappear  entirely 


3o6  PSYCHIATRY 

and  the  defects  in  memory  become  less  marked.  Sometimes 
the  insane  ideas  gradually  diminish,  until  the  patient  gains 
considerable  insight  into  his  own  condition.  As  a  rule,  how- 
ever, there  is  a  marked  feeling  of  complacency,  and  the  patient 
fails  to  show  by  any  emotional  reaction  an  exact  appreciation 
of  his  condition.  Individuals  may  remain  in  this  stage  for 
years,  periods  of  remission  not  infrequently  alternating  with 
states  characterized  by  an  increase  in  the  number  of  insane 
ideas  or  in  more  intense  periods  of  depression.  The  intel- 
lectual defects  continue,  so  that  these  patients  are  never  capa- 
ble of  undertaking  any  task  which  involves  the  expenditure 
of  any  considerable  mental  effort.  Occasionally  individuals  re- 
cover sufficiently  to  leave  the  institution  and  to  engage  in 
some  form  of  occupation  free  from  any  great  degree  of  re- 
sponsibility. After  the  lapse  of  a  period  of  years  the  dementia 
may  become  much  more  pronounced.  As  a  rule,  it  is  compli- 
cated by  symptoms  which  suggest  the  existence  of .  arterio- 
sclerosis as  well  as  of  cerebral  softening.  Not  infrequently 
cases  are  met  with  in  which  the  diagnosis  from  general  de- 
mentia paralytica  is  very  difficult.  In  these  instances  the 
motor  symptoms — tremor,  disturbances  of  speech,  incoordi- 
nated  muscular  movements — are  marked.  For  the  most  part 
the  Argyll-Robertson  pupil  and  the  disturbances  of  the  bladder 
and  rectum,  depending  upon  lesions  in  the  spinal  cord,  render 
the  diagnosis  of  dementia  paralytica  probable.  This  latter  dis- 
ease is  characterized  by  remissions  which  are  only  transitory, 
while  in  the  pure  alcoholic  psychoses  they  may  extend  over 
a  period  of  years,  so  that  not  uncommonly  the  disease  process 
is  apparently  stationary.  In  some  few  cases  recovery  has 
been  reported,  but  it  is  highly  probable  that  if  a  thorough 
examination  were  made  some  psychic  defect  could  be  noted. 

Alcoholism.  Paranoioid  State  with  Partially  Retained  Insight 
into  Condition. — Johns  Hopkins  Hospital  Dispensary.  Male,  aged  38. 
United  States.  Married.  Painter.  Admitted  April  26,  1904.  Complains 
of  nervousness  and  that  the  people  with  whom  he  used  to  live  do  not  treat 
him  well. 

Family  History. — Negative  for  nervous  and  mental  diseases. 


PARANOIIC    STATES  307 

Personal  History. — Measles,  whooping-cough,  chills  and  fever  at  about 
15.  Gonorrhoea  at  19.  No  definite  luetic  history.  When  he  was  20  years 
old  he  began  to  indulge  in  alcoholic  excesses.  Every  three  or  four  months 
he  would  go  on  a  spree.  This  continued  up  to  five  years  ago,  when  he 
stopped  these  excesses  because  he  thought  they  were  doing  him  harm. 
Has  never  had  delirium  tremens.  One  day  he  fell  in  the  street  and  lost 
consciousness ;  had  a  slight  "  spell."  Was  taken  home  by  a  friend,  and 
has  had  no  similar  attack.  Married  two  years  ago.  Wife  well  and  strong. 
The  patient  has  not  touched  any  liquor  for  a  year  and  a  half.  Smokes  a 
good  deal, — twelve  pipes  a  day.  It  is  impossible  to  obtain  a  definite  his- 
tory as  to  whether  he  was  sometimes  neurotic,  although  he  himself  thinks 
that  he  was.    He  has  never  had  any  symptoms  of  lead  poisoning. 

Present  Illness. — His  wife  says  that  about  two  years  ago  her  husband 
after  a  period  of  abstinence  drank  excessively  and  became  very  nervous 
and  suspicious.  He  thought  that  the  people  he  noticed  talking  to  each 
other  on  the  street  were  directing  their  remarks  against  him.  When  ques- 
tioned about  this,  the  patient  says  that  at  the  time  he  was  not  sure  that 
they  were  talking  against  him,  but  now  he  is  confident  that  they  were.  The 
reason  for  this  positive  affirmation  is  that  he  has  so  frequently  heard  what 
they  said  and  the  voices  have  been  so  plain  that  he  can  no  longer  doubt. 
About  a  year  ago  he  supposed  that  a  number  of  lodgers  at  the  big  boarding- 
house  in  which  he  lived  annoyed  him.  The  patient  affirms  that  he  fre- 
quently overheard  these  former  companions  say,  "  We  will  lay  for  him  on 
his  way  to  work  and  we'll  kill  him."  He  knows  of  no  reason  for  their 
doing  this  except  that  they  were  patrons  of  the  boarding-house  of  which 
he.  was  janitor  and,  as  they  were  all  excessive  drinkers,  they  took  great 
exception  to  the  patient's  interference  with  their  sprees.  No  actual  violence 
was  ever  attempted  by  them.  Frequently  at  night,  when  the  patient  was 
lying  awake,  he  would  hear  them  talking  in  the  next  room  and  threatening 
violence.  A  curious  thing  about  it  all  was  that  the  patient  at  this  time 
never  saw  his  supposed  enemies,  but  only  heard  them  speaking  outside  of 
his  door.  These  suspicions  have  continued  pretty  constantly,  and  within 
the  past  two  years  the  patient  and  his  wife  have  changed  their  place  of 
residence  three  times  in  order  to  escape  from  his  supposed  persecutors. 
The  patient  is  sometimes  afraid  to  go  out,  as  he  fears  that  these  enemies 
will  pounce  upon  him.  Occasionally,  when  he  is  walking  along  the  street, 
he  first  experiences  a  curious  sensation  that  somebody  is  following  him  and 
then  turns  to  look,  when  his  fears  are  confirmed  by  actually  seeing  some 
one.  The  patient's  wife,  who  is  a  very  sensible,  phlegmatic  person,  says 
that  there  is  no  truth  in  the  statements  made  by  the  patient.  At  night  he  is 
frequently  sleepless  and  asks  his  wife  if  she  hears  the  voices  in  the  adjoin- 
ing room.  He  cannot  be  made  to  believe  that  nobody  is  speaking.  When 
the  patient  is  asked  if  he  will  not  admit  that  his  present  condition  might 
be  the  result  of  his  former  habits,  he  is  quite  willing  to  agree  that  his 
nervousness  and  sleeplessness  and  generally  run-down  condition  are  the 
result  of  his  excessive  indulgence  in  alcohol,  but  says  that  the  voices  are 
too  real  and  too  constant  for  him  to  believe  that  they  too  are  the  result 
merely  of  his  disordered  nervous  system. 


3o8  PSYCHIATRY 

The  patient  was  well  oriented  in  time  and  space,  was  not  emotional, 
gave  a  connected  account  of  himself,  although  apparently  he  had  little 
interest  in  matters  outside  of  his  own  immediate  condition.  He  was  in- 
different to  the  fact  that  his  wife  worried  considerably  about  his  present 
condition,  being  quite  self-centred  and  somewhat  egotistical.  As  the 
somatic  symptoms  have  no  immediate  bearing  upon  the  mental  state,  they 
have  been  omitted  from  this  abstract.  When  last  heard  of,  the  patient  had 
left  his  home  and  his  wife  had  no  knowledge  of  his  whereabouts. 

Complications  of  various  kinds  may  occur  during  the 
course  of  delirium  tremens  and  the  alcoholic  psychoses,  the 
acute  as  well  as  the  more  chronic  forms.  Epileptiform  con- 
vulsions not  infrequently  occur.  At  times  the  attacks  of  petit 
or  grand  mal  follow  excessive  alcoholic  indulgence,  but  in  these 
cases  alcohol  is  the  exciting  factor,  not  the  main  cause.  It 
has  already  been  pointed  out  that  epileptics  are  markedly  sus- 
ceptible to  the  effects  of  alcohol.  On  account  of  their  emo- 
tional instability  such  patients  not  infrequently  resort  to 
liquor,  for  the  reason  that  they  sometimes  feel  the  need  of  a 
stimulant,  more  especially  during  the  periods  of  depression 
either  preceding  or  following  the  attacks.  Many  cases  of  peri- 
odic drinking,  or  dipsomania,  may  be  attributed  to  epilepsy. 
In  a  large  number  of  chronic  drinkers  a  history  of  fainting 
spells,  temporary  attacks  of  amnesia,  mild  degrees  of  aphasia, 
etc.,  as  well  as  the  severer  forms  of  epilepsy,  can  be  elicited. 
The  association  of  hysterical  symptoms  with  alcoholism  has 
not  infrequently  been  noted. 

It  should  be  borne  in  mind  that  alcoholism  may  be  com- 
plicated by  various  diseases.  The  variety  of  lesions  caused 
by  the  action  of  the  drug  is  very  great,  and  these  may  in  turn 
give  rise  to  symptoms.  In  the  vascular  system  we  find  fatty 
and  atheromatous  degeneration;  at  least  one-fourth  of  all 
the  cases  of  arteriosclerosis  are  said  by  some  clinicians  to  be 
due  to  alcoholism.  Nor  should  it  be  forgotten  that  arterio- 
sclerosis gives  rise  to  an  intolerance  of  even  small  quantities 
of  the  drug  and  that  this  may  be  one  of  the  earliest  symptoms 
of  vascular  disease. 

Myocarditis  and  a  dilated  heart  are  frequently  observed. 
Various  forms  of  nephritis  are  met  with,  particularly  the  con- 


ALCOHOLISM  ,_„ 

tracted  kidney  and  fatty  degeneration  of  the  renal  cells.     The 
liver,  as  well  as  the  gastro-intestinal  tract,  is  nearly  always  af- 
fected.   The  relationship  of  gout  to  chronic  alcoholism  has  been 
referred  to  by  many  authors.     Sugar  is  not  infrequently  found 
in   the   urine   of  patients    suffering    from    delirium    tremens. 
Rosenberger  and  Arndt  noted  the  occurrence  of  glycosuria  in 
the  initial  stages  of  the  disease,19  but  Reuter  found  that  if  the 
patients  were  put  on  a  restricted  diet  the  sugar  disappeared, 
and  from  this  inferred  that  the  ingestion  of  alcohol  with  an 
excess  of  carbohydrates  predisposed  individuals  to  glycosuria. 
The  development  of  a  true  diabetes  from  these  transitory  gly- 
cosurias has  never  been  reported.    As  has  been  said  before,  the 
susceptibility  of  alcoholics  to  infection  is  well  known.     Re- 
cently considerable  attention  has  been  directed  to  the  relation 
of  many  cases  of  alcoholism  and  tuberculosis.20   The  effects  of 
the  drug  in  disturbing  the  functions  of  the  circulation,  respi- 
ration, and  digestion  so  lower  the  resistance  of  the  organism 
as  to  make  the  individual  particularly  liable  to  tuberculous  in- 
fection.    This  theory  receives  still  further  confirmation  in  the 
tendency  shown  by  the  children  of  alcoholic  parents  to  fall  a 
prey  to  the  latter  disease. 

Etiology  and  Treatment.— As  the  successful  treatment 
of  alcoholism  in  all  forms  necessitates  a  knowledge  of  the 
causes  that  have  given  rise  to  the  disorder,  these  two  topics 
may  be  conjointly  discussed.  The  most  important  factor  of 
all  is  the  attempt  to  prevent  the  spread  of  alcoholism.  Al- 
though this  is  supposed  to  be  a  sociological  question,  its  ulti- 
mate solution  rests  largely  with  the  medical  profession.  As 
White  21  has  well  said,  "  The  causes  of  drinking  are  infinitely 
varied  and  intimately  bound  up  in  the  heart  of  man,— at  once 
an  expression  of  his  strength  and  his  weakness,  his  successes 
and  his  failures."     In  a  country  in  which  every  attempt  is 

19  Reuter,  K. :    Ueber  Alkoholglykosurie.     Mitteilungen  aus  dem  Ham- 
burger Staatskrankenhause.     igoi. 

20  Stein-Orvosi,  Hetilap.,  1903,  No.  45. 

w  J?  White :    Alcoholic  and  Drug  Intoxication.     Reference  Handbook  of 
Medical  Sciences,  vol.  v,  p.  81. 


310  PSYCHIATRY 

being  made  to  educate  the  masses,  it  should  not  be  forgotten 
that  the  elevation  of  an  individual  out  of  the  sphere  into  which 
he  was  born  may  impose  a  tax  upon  the  functions  of  his  ner- 
vous system  which  may  eventually  expose  him  to  serious  temp- 
tations. The  frequency  with  which  neuroses  and  psychoses 
appear  in  families  in  which  there  has  been  a  sudden  and  rapid 
change  in  environment — for  example,  a  removal  from  country 
to  city  life — is  a  factor  of  great  importance  and  should  re- 
ceive most  careful  consideration.  The  addiction  to  alcohol 
is  a  symptom  of  a  functionally  unstable  nervous  system,  and 
the  contrary  view  entertained  by  the  laity  is  not  justified  by 
clinical  observation  or  experience.  Under  the  stress  of  the 
conditions  created  by  modern  civilization,  many  individuals 
in  the  social  organism,  in  attempting,  as  they  suppose,  to  better 
their  condition,  are  thrown  out  of  sympathy  with  their  sur- 
roundings and  thus  become  subjected  to  excessive  nervous 
strain.  Alcoholism,  the  various  drug  habits,  and  the  tendency 
shown  by  the  public  to  indulge  in  quack  medicines  may  simply 
be  regarded  as  different  phases  of  this  general  mental  and  phy- 
sical instability.  A  great  deal  can  unquestionably  be  done  by 
physicians  in  educating  the  public  to  mitigate  these  evils. 
Careful  instruction  should  be  given  in  the  public  schools  re- 
garding the  effects  of  alcohol;  but,  unfortunately,  much  that 
is  now  given  is  based  upon  imperfect  observation,  and  the  facts 
are  so  distorted  by  fanatical  enthusiasm  that,  to  say  the  least, 
little  good  has  thus  far  been  done.  Greater  care  should  be 
taken  in  regard  to  the  expression  of  generalizations  in  relation 
to  the  causes  of  alcoholism  and  the  best  methods  of  preventing 
its  spread.  There  is  no  question  of  public  interest  that  is  in 
greater  need  of  being  studied  by  sober-minded  individuals. 
The  causes  are  in  many  instances  so  complex  and  so  far-reach- 
ing in  their  consequences  that  a  very  careful  analysis  of  the 
facts  is  desirable  before  this  question  can  be  successfully  dealt 
with.22 


22  Helenius,  Matti :   Die  Alkoholfrage.     Eine  soziologisch-statische  Un- 
tersuchung.    Jena.     Gustav  Fischer. 


ALCOHOLISM  31 1 

Therapeutic  measures  in  all  forms  of  acute  alcoholism  can 
be  directed  merely  to  combating  the  individual  symptoms.  In 
the  acute  delirious  states  the  drug  should  be  withdrawn  with 
the  greatest  care.  To  withhold  it  completely  at  once  in  some 
instances  causes  an  intensification  of  the  symptoms  and  gives 
rise  to  serious  interference  with  the  action  of  the  heart.  With 
care,  however,  caffein,  camphor,  and  other  forms  of  cardiac 
stimulants  may  be  substituted  as  occasion  requires.  The  pa- 
tient during  the  acute  stages  should  be  kept  in  bed,  preferably 
isolated  so  that  he  may  be  removed  from  all  forms  of  external 
stimulation.  The  motor  restlessness,  when  present,  is  best 
treated  by  the  prolonged  bath  given  under  careful  supervision ; 
or,  if  this  procedure  is  not  well  tolerated,  the  warm  pack  may 
be  tried.  If  the  restlessness  is  not  quieted  by  means  of  the 
bath,  various  sedatives  may  be  used  with  care, — morphin,  the 
bromides,  chloral,  and  hyoscin.  The  complications  must  be 
treated  symptomatically  as  they  arise.  In  cases  in  which  there 
is  a  complicating  nephritis,  it  may  be  necessary  to  give  the 
patient  hot-air  baths.  The  diet  should  consist  of  fluids,  pref- 
erably milk,  given  in  small  quantities  frequently  repeated. 
At  times  the  gastric  disturbances  are  so  marked  that  patients 
will  not  retain  any  nourishment,  and  feeding  by  enemata  must 
be  resorted  to.  As  the  patient  improves,  feeding  should  be 
forced  as  much  as  possible.  As  a  rule,  food  is  better  tolerated 
when  given  in  small  quantities  and  repeated  at  intervals  of 
two  or  three  hours.  Strychnin,  administered  either  by  the 
mouth  or  subcutaneously,  has  been  highly  recommended.  In 
some  cases  the  drug  certainly  seems  to  prove  of  considerable 
benefit,  but  it  should  not  be  looked  upon  in  any  sense  as  a 
specific. 

In  the  more  chronic  forms  it  is  of  prime  importance  that 
the  patient  be  made  to  realize  the  importance  of  total  absti- 
nence, not  only  from  alcohol  but  from  all  forms  of  stimulants. 
Each  case  must  be  studied  upon  its  own  merits,  and  the  exciting 
causes  that  have  given  rise  to  the  tendency  to  excesses  in  alco- 
hol must  be  combated.  This  frequently  necessitates  a  change 
in  the  individual's  mode  of  life  and  in  his  environment.     Emo- 


312  PSYCHIATRY 

tional  disturbances  of  any  form  should  as  far  as  possible  be 
avoided.  The  impulses  to  take  alcohol  are  as  much  the  out- 
come of  excessive  pleasurable  feelings  as  they  are  of  dis- 
comfort or  actual  pain.  The  majority  of  patients,  when  they 
have  recovered  from  the  acute  stages,  are  better  off  in  a  mild 
climate  not  subject  to  great  variations  of  temperature  than 
in  one  in  which  the  changes  are  excessive  and  sudden.  Much 
has  been  written  about  the  use  of  hypnotic  suggestion  in  the 
treatment  of  these  cases,  and  it  can  not  be  denied  that  in  some 
hysterical  patients  satisfactory  results  have  been  obtained,  and 
to  its  influence  must  largely  be  attributed  many  of  the  adver- 
tised cures, — only  a  small  minority  of  which,  however,  are 
genuine.  The  alcoholic  is  a  neurotic  individual  and  is  par- 
ticularly open  to  suggestion.  But  it  should  not  be  forgotten 
that  the  use  of  mental  suggestion  not  infrequently  makes  the 
case  worse  rather  than  better.  The  individual  should  be  shown 
how  to  successfully  cultivate  and  train  his  volitional  powers 
and  should  not  be  taught  to  rely  upon  quack  cures.  What  are 
particularly  needed  in  this  country  are  small  sanitaria,  under 
the  direction  of  thoroughly  competent  and  well-trained  medi- 
cal men,  situated  in  the  country  within  easy  reach  of  cities, 
where  patients  of  this  class  may  be  sent  for  treatment.  The 
patient  should  be  under  constant  supervision,  should  have 
enough  but  not  too  severe  exercise;  all  forms  of  amusement 
as  well  as  of  mental  occupation  should  be  definitely  prescribed, 
and  as  far  as  possible  these  individuals  should  be  taught  how 
to  live.  Such  patients  should  be  kept  under  observation  for 
a  considerable  period  of  time  after  the  symptoms  of  alienation 
have  subsided.  At  least  a  year  under  medical  supervision  is 
necessary  before  the  individual  has  regained  sufficient  nerve 
force  to  enable  him  to  resist  a  return  to  his  former  habits. 

Pathological  Anatomy. — For  a  full  description  of  the 
changes  that  occur  in  the  internal  viscera  in  chronic  alcohol- 
ism the  reader  is  referred  to  the  text-books  on  clinical  medi- 
cine and  general  pathology. 

Of  the  lesions  in  the  central  nervous  system  due  to  the 


ALCOHOLISM  -„ 

action  of  alcohol  none  is  specific.23     In  the  observations  made 
upon  animals  which  have  been  given  repeated  doses  of  the  drug 
extending  over  long  periods  of  time,  in  addition  to  inflamma- 
tory changes  in  the  pia,  fatty  degenerations  in  the  connective- 
tissue  substance  and  the  blood-vessels,  and  vacuolization,  with 
atrophy  of  the  cortex,  have  been  frequently  noted.     The  opin- 
ion is  steadily  gaining  ground  that  the  effect  of  alcohol  alone 
does  not  produce  a  psychosis,  but  rather  gives  rise  to  certain 
tendencies  which  are  of  etiological  importance.     It  is  as  yet 
unknown  why  the  drug  should  affect  different  portions  of  the 
central  nervous  system  in  different  individuals.     As  has  fre- 
quently  been   pointed   out,    the    locus   minoris    resistentiae    is 
sometimes  in  the  vascular  system  and  again  in  the  meninges, 
the  latter  being  found  affected  in  nearly  every  case.     Gener- 
ally there  are  a  marked  opacity  and  thickening  of  the  pia  over 
the  convexity  and  not  infrequently  an  ependymitis.     Pachy- 
meningitis hemorrhagica  is  met  with  and  adhesions  between 
the  dura  and  the  skull  of  inflammatory  origin  are  common. 
The  vessels,  as  a  rule,  are  affected,  although  Cramer  reports 
two  cases  of  chronic  alcoholism,  in  both  of  which  during  life 
there  had  been  evidences  of  considerable  dementia  but  in  which 
there  were  no  sclerotic  changes  noticeable  in  the  larger  arteries. 
These  findings  do  not  substantiate  the  views  of  those  who 
maintain  that  the  changes  in  chronic  alcoholism  are  always 
associated  with  marked  vascular  lesions.     In  one  case  reported 
there  was  a  dilatation  of  the  medium-sized  and  large  arteries 
and  veins  with  hyaline  degeneration  of  the  walls.     In  some 
instances  the  lumina  of  vessels  were  narrowed  and  obliterated. 
Red  and  white  blood-cells  were  found  between  the  different 
layers  of  the  walls  of  these  vessels.     The  lymph-spaces  were 
dilated,   the  glia   was   increased,    and   many   monster   spider- 
cells  were  found,  particularly  in  the  neighborhood  of  the  ves- 


23  Cole:  Changes  in  the  Central  Nervous  System  in  the  Neuritic  Dis- 
orders of  Chronic  Alcoholism.  Brain,  Autumn,  1902.  Systematic  Exam- 
ination of  the  Central  and  Peripheral  Nervous  System  and  Muscles  in  a 
Case  of  Acute  Alcoholic  Paralysis  with  Mental  Symptoms.  Archives  of 
Neurology,  ii,  p.  835. 


314 


PSYCHIATRY 


sels.  In  the  cases  which  run  an  acute  course  and  where  the 
mental  disturbances  are  very  severe,  the  changes  in  the  glia, 
as  a  rule,  are  well  marked.  In  some  instances  there  is  atrophy 
of  the  convolutions  with  a  disappearance  of  the  medullated 
fibres. 

In  cases  of  delirium  tremens  Bonhoeffer  24  and  Troem- 
ner25  failed  to  find  any  specific  changes.  The  former  noted 
a  dissolution  of  the  chromatic  substance,  particularly  in  the 
large  giant  cells  of  the  central  convolution.  This  was  asso- 
ciated with  granular  degeneration  and  change  in  the  contour 
of  the  cell,  which  argued  the  existence  of  a  pathological 
process  of  great  severity.  In  some  instances  the  nucleus  was 
eccentric;  in  others  it  was  in  its  normal  position,  although 
frequently  shrunken  in  appearance.  The  Purkinje  cells  were 
normal.  Troemner  affirmed  that  the  pathological  process  due 
to  alcohol  is  more  or  less  diffuse.  In  the  sections  examined 
the  lesions  in  the  occipital  region,  however,  were  less  exten- 
sive than  in  other  areas.  The  subpial  glia  felting  was  in- 
creased in  quantity.  The  vessels  were  thickened  and  there 
were  fatty  degeneration  of  the  intima  and  small-celled  infil- 
tration of  the  media.  The  inclination  to  hemorrhages  was 
marked,  particularly  in  the  central  and  frontal  convolutions. 
A  spot  of  predilection  was  the  gray  substance  about  the  third 
ventricle  and  the  aqueduct  of  Sylvius. 

Ether. — Although  in  some  countries,  particularly  Ireland 
and  certain  parts  of  Prussia,  this  drug  is  habitually  taken  in  the 
form  of  inhalations,  such  cases  are  not  common  in  America, 
although  they  are  occasionally  met  with,  more  particularly 
among  the  higher  social  classes.  For  a  detailed  description  of 
the  acute  ether  intoxication  the  reader  is  referred  to  the  various 
text-books  which  deal  fully  with  the  subject.  As  would  be  ex- 
pected, the  continued  use  of  the  drug  has  a  marked  effect  not 

24  Pathologisch-anatomische  Untersuchungen  an  Alkoholdeliranten. 
Monatsschr.  f.  Psych.,  Bd.  x,  S.  265. 

25  Pathologisch-anatomische  Befunde  bei  Delirium  tremens  nebst 
Bemerkungen  zur  Struktur  der  Ganglienzellen.  Arch.  f.  Psych.,  Bd.  xxxi, 
H.  3. 


CHLOROFORM  3!5 

only  upon  the  kidneys,  liver,  and  heart,  but  also  upon  the  mental 
faculties,  giving  rise  to  hysterical  states  or  hallucinatory  dis- 
turbances which  are  apt  to  be  combined  with  impulsive  acts. 

Chloroform. — Psychoses  occasionally  follow  the  admin- 
istration of  chloroform,  but  instances  in  which  mental  aberra- 
tion persists  for  a  considerable  length  of  time  after  the  with- 
drawal of  the  drug  are  rare.  That  such  are  not  unknown,  how- 
ever, is  evident  from  certain  references  that  appear  throughout 
the  medical  literature.26  Thus  in  one  instance,  after  only  15 
cubic  centimetres  of  the  drug  had  been  taken  by  inhalation, 
marked  mental  aberration  occurred  lasting  for  half  an  hour 
after  the  cessation  of  the  anaesthesia.  The  patient  was  greatly 
excited  and,  although  able  to  leave  the  room,  failed  to  recognize 
those  about  him,  mistook  the  physician  for  a  comrade,  and 
showed  marked  disorientation  for  time  and  place.  The  delir- 
ium lasted  for  over  half  an  hour  and  then  gradually  cleared 
up.  In  some  cases  the  tendency  to  pseudoreminiscence  is  very 
marked  and  disorientation  for  time  and  place  is  nearly  always 
present.  A  few  cases  have  been  recorded  in  which  the  confu- 
sion lasted  for  from  two  to  five  days.  Although  delirious  states 
are  more  common,  cases  have  been  reported  in  which  the  pa- 
tients sank  into  a  deep  stupor,  in  one  instance  lasting  for  three 
days.  Somewhat  similar  conditions  have  been  reported  after 
the  administration  of  other  drugs,  such  as  ether,  ethyl  bromide, 
iodoform.27  These  mental  disturbances  are  supposed  to  be 
caused  indirectly  by  an  autointoxication  resulting  from  the 
administration  of  the  drug,  but  in  all  probability  the  predis- 
position of  the  individual  is  a  very  important  factor. 

Inasmuch  as  the  manner  in  which  chloroform  and  allied 
drugs  act  is  not  understood,  it  is  not  surprising  that  nothing 
definite  is  known  regarding  the  pathology  of  these  conditions. 
Heger  thought  that  in  profound  anaesthesia  there  was  a  con- 

26  Scheuerer,  Franz :  Beitrage  zur  Frage  der  Chloroformpsychose. 
Psych.  Neurol.  Wchnschr.,  1904,  Nr.  46  und  47. 

27  Schlesinger :  Die  bei  der  Behandlung  mit  Iodoform  auftretenden 
Psychischen  Storungen.  Allg.  Ztschr  f.  Psych.,  Bd.  liv,  H.  6.  Nach. 
Deut.  med.  Wchnschr.,  1898,  Litt.  Beil,  Nr.  18,  S.  120. 


3i6  PSYCHIATRY 

traction  of  the  cell-body  and  a  moniliform  condition  of  the  den- 
drites, a  change  demonstrable  in  animals  to  whom  ether,  chloro- 
form, chloral,  or  morphin  had  been  given.  Binswanger  has 
advanced  the  hypothesis  that  a  temporary  disturbance  in  the 
function  of  the  nerve-cell  is  caused  by  the  loss  of  nutritive 
material  due  to  the  molecular  changes  in  the  Nissl  granules. 
As  a  result  of  these  simple  disturbances  of  nutrition,  which  may 
occur  in  states  of  exhaustion,  inhibitory  processes  are  supposed 
to  be  initiated  which  are  an  expression  of  an  irregularity  in  the 
functions  of  the  cell,  and  the  synthetic  processes  in  the  cell  are 
thus  hindered.  Cloetta,28  following  Meyer  and  Overton,  affirms 
that  all  narcotic  drugs  have  a  common  characteristic  of  going 
into  solution  in  oil  to  a  degree  proportional  to  their  narcotic 
power;  but  as  the  nervous  system  is  particularly  rich  in  sub- 
stances which  are  closely  allied  to  the  fats,  instead  of  an  actual 
chemical  change  one  of  a  more  purely  physical  character  takes 
place.  They  think  that  the  liver  has  a  great  affinity  for  the 
chloroform  circulating  in  the  blood  and  that  this  organ,  rich  in 
such  fatty  substances  as  cholesterin  and  lecithin,  has  the  power 
of  combining  physically  with  chloroform,  ether,  and  other  nar- 
cotics of  the  aliphatic  series,  such  as  sulphonal,  chloral,  and 
paraldehyde. 

Paraldehyde. — As  this  drug  was  largely  used  a  few 
years  ago  in  the  treatment  of  alcoholism  and  morphinism,  it 
should  not  be  a  matter  of  surprise  that  the  original  habit  was 
often  exchanged  for  the  more  novel  vice.  The  effects  of  paral- 
dehyde in  comparatively  large  doses  are  very  similar  to  those 
of  alcohol,  but  the  immediate  manifestations  are  much  more 
quickly  observed.  Cases  are  on  record  in  which  the  continued 
use  of  the  drug  resulted  in  marked  impairment  of  the  nutrition, 
great  loss  of  weight,  and  auditory  hallucinations,  this  more  or 
less  chronic  state  being  superseded  by  an  acute  exacerbation, 
the  symptoms  of  which  were  remarkably  similar  to  those  of 
delirium  tremens.     Visual  and  auditory  hallucinations,  as  well  as 


28  Cloetta,  M. :    Ueber  den  Unterricht  in  der  Arzneimittellehre.     Munch, 
med.  Wchnsch.,  1902,  Nr.  1,  S.  25,  ff. 


MORPHINISM  3!7 

those  of  smell  and  touch,  predominate,  accompanied  by  marked 
tremor,  obstinate  insomnia,  some  difficulty  in  speech,  and  dimi- 
nution in  the  power  of  orientation.29  Nevertheless,  some  ob- 
servers believe  that  considering  the  great  frequency  with  which 
the  drug  is  administered  the  cases  which  present  the  foregoing 
symptoms  form  a  very  small  minority.30 

Morphinism.31 — In  this  country  patients  become  addicted 
to  morphin  more  commonly  than  to  other  forms  of  opiates, 
although  opium-eating  and  opium-smoking,  unfortunately,  are 
not  very  rare  in  America.  The  development  of  this  habit  de- 
pends upon  a  great  variety  of  conditions  and  each  case  needs  to 
be  studied  by  itself.  Not  a  few  patients  gradually  become 
habituated  to  the  vice  from  the  fact  that  the  drug  is  too  often 
prescribed  for  long  periods  of  time  by  physicians  for  the  relief 
of  pain  in  chronic  neuralgia,  sciatica,  insomnia,  and  nervous- 
ness, or  in  women  for  dysmenorrhea.  In  many  patients,  par- 
ticularly among  the  wealthier  classes,  subcutaneous  injections 
are  resorted  to.  As  a  rule,  those  who  begin  by  taking  opium 
later  on  become  addicted  to  the  alkaloid. 

The  mental  symptoms  of  morphinists  are  varied  and  in  the 
main  have  certain  general  characteristics  which  aid  in  the 
recognition  of  the  disease.  In  the  earlier  stages,  and  before  the 
patient  has  become  a  thorough  slave  to  the  habit,  he  is  apt  to 
show  marked  symptoms  of  hysteria.  At  times  states  of  appre- 
hensiveness  and  anxiety  develop;  the  patient  readily  becomes 
flustered,  often  develops  mild  suspicions,  is  decidedly  pessi- 
mistic and  hypersensitive,  affirms  that  old  friends  are  forsaking 
him,  that  all  his  actions  are  misinterpreted.  Soon  ethical  de- 
fects become  more  or  less  pronounced.  A  tendency  to  lie,  par- 
ticularly when  questioned  in  regard  to  his  failing,  is  developed, 
and  as  action  becomes  more  difficult  the  fabrications  increase  in 


29Behr,    A.:      Beitrag    zur     Kasuistik    der     Paraldehyddelirien.       St. 
Petersb.  med.  Wchnschr.,  1902,  Nr.  14. 

30  Bemke :    Paraldehyd  als  Schlafmittel.    Monatsschr.  f.  Psych,  u.  Neu- 
rol., Bd.  xii,  Dezr.,  1902,  H.  6. 

31  Schutze :    Zur   Casuistik   des   chronischen   Morphinismus.     Charite- 
Annalen,  xxvi,  1902. 


3i8  PSYCHIATRY 

scope  and  variety.  The  sense  of  duty  becomes  more  and  more 
blunted  till  it  finally  disappears.  The  patient  becomes  decidedly 
apathetic,  is  lacking  in  all  altruistic  qualities,  and  shows  himself 
regardless  of  all  duties  except  those  connected  with  his  own 
energies.  The  whole  character  deteriorates  and  the  defects  are 
in  many  respects  similar  to  those  belonging  to  certain  stages  in 
alcoholism  although  they  altogether  differ  from  others.  These 
individuals  will  resort  to  any  kind  of  subterfuge  in  order  to 
obtain  a  supply  of  the  drug,  and  if  they  have  any  in  their  pos- 
session, whenever  they  expect  a  visit  from  attendants  or  physi- 
cians, they  find  various  hiding-places  for  it  or  conceal  it  about 
their  persons.  The  ingenuity  shown  by  some  patients  in  this 
respect  is  extraordinary.  As  would  naturally  be  inferred,  all 
association  processes  are  seriously  interfered  with,  the  degree 
of  the  disturbance  depending  largely  upon  individual  idiosyn- 
crasies and  the  amount  of  the  poison  taken.  Thus  every  grade 
is  encountered  from  slight  inhibition  or  incoherence  to  deep 
somnolence  or  stupor.  In  the  earlier  stages  and  in  certain  in- 
dividuals, even  when  large  doses  are  taken,  there  may  be  an 
abnormal  irritability  and  a  tendency  to  talk,  the  apparent 
flight  of  ideas  and  general  motor  restlessness  being  very  sug- 
gestive of  alcoholism.  Hallucinations  and  delusions  may 
develop,  although  they  are  not  usually  present  unless  the  mor- 
phinism is  complicated  by  alcoholism  or  the  effects  of  some 
other  drug.  The  visual  as  well  as  the  auditory  hallucinations, 
as  a  rule,  are  of  a  definite  elementary  character — bright  or 
colored  flashes  of  lightning,  sparks,  sounds,  the  ringing  of 
bells,  etc.  Moreover,  these  patients  are  not  uncommonly  suf- 
ferers from  psychsesthesias,  paresthesias,  or  less  frequently 
hypersesthesias. 

The  physical  symptoms  of  these  cases  in  a  measure  depend 
upon  the  individual  reaction  to  a  variety  of  conditions.  When 
the  habit  has  existed  for  any  length  of  time  the  patients  show 
an  obstinate  aversion  to  food  and  an  utter  disinclination  for 
any  form  of  exercise;  as  a  result  they  become  anaemic,  and 
develop  a  more  or  less  marked  cachexia.  Furunculosis  is  not 
uncommon,    particularly   in   those   who   use  the   drug  hypo- 


MORPHINISM 


319 


dermically.  The  breath  is  generally  foul,  the  teeth  show  signs 
of  neglect,  the  hair  becomes  dry  and  shows  a  tendency  to  fall 
out.  As  would  naturally  be  expected,  there  are  marked  dis- 
turbances in  the  circulation.  The  extremities  are  apt  to  be 
cold;  the  superficial  circulation  is  poor;  the  heart  is  rapid 
and  becomes  more  or  less  irregular.  Disturbances  of  vary- 
ing intensity  in  the  gastro-intestinal  tract  are  constant,  and 
the  patients  usually  suffer  from  anorexia,  flatulence,  and  at- 
tacks of  diarrhoea  alternating  with  obstinate  constipation. 
Even  in  the  earlier  stages  the  pupils  of  the  eyes  are  contracted 
and  are  sometimes  reduced  almost  to  the  size  of  pin-points. 
The  reactions  for  light  and  accommodation  are  usually  im- 
paired. 

Anomalies  in  the  muscular  power  are  generally  well 
marked  and  are  more  or  less  dependent  upon  the  psychic  state. 
The  disinclination  to  exercise  or  to  make  any  effort  is  reflected 
in  the  general  character  of  the  patient.  The  muscles  become 
flaccid,  the  gait  is  hesitating,  and  all  volitional  movements  are 
more  or  less  impaired.  Quite  commonly  a  pronounced  inten- 
tion tremor  and  in  some  cases  very  marked  incoordination 
of  all  muscular  movements  and  Romberg's  symptom  develop. 
In  such  cases,  however,  it  always  becomes  necessary  to  exclude 
some  complication.  The  disturbances  in  sensation  are  varied 
and  are  largely  of  central  origin.  The  sexual  functions  are 
usually  diminished,  although  in  rare  instances  a  condition  of 
excitability  has  been  reported.  In  addition  to  the  symptoms 
already  described  a  few  observers  have  called  attention  to  the 
occurrence  of  epileptiform  attacks  as  well  as  those  suggestive 
of  pseudo-angina.  Variations  in  temperature,  with  occasional 
rises  even  to  39  °  or  40 °  C,  are  not  uncommon  in  morphino- 
maniacs,  but  since  experiments  on  animals  would  indicate  that 
injections  of  morphin  are  followed  by  a  lowering  of  the  tem- 
perature, we  must  infer  that  in  some  cases  at  least  such  rises  are 
due  to  a  localized  infection  following  a  careless  injection. 
Nevertheless,  in  other  cases  the  febrile  disturbances  must  prob- 
ably be  regarded  as  the  result  of  secondary  intoxications  due  to 
the  gastro-intestinal  disturbances.    These  individuals  usually  in 


320 


PSYCHIATRY 


the  end  die  of  some  intercurrent  trouble,  the  cachexia  being 
often  a  very  important  factor. 

Delirious  states,  particularly  a  form  closely  resembling 
delirium  tremens,  may  develop.  Sometimes  late  in  the  disease 
coma  or  convulsions  supervene.  During  the  period  of  absti- 
nence, particularly  if  the  individual  has  been  addicted  to  the 
use  of  the  drug  for  any  length  of  time,  the  untoward  symptoms 
are  temporarily  liable  to  be  greatly  exaggerated.  The  patient 
beomes  excessively  irritable  and  gives  vent  to  outbursts  of  tem- 
per; the  gastro-intestinal  disturbances  increase  and  in  some 
cases  there  develop  visual  and  auditory  hallucinations  with 
marked  delirious  states,  accompanied  by  suicidal  and  homicidal 
impulsions. 

The  treatment  of  these  cases  is  very  difficult  and  frequently 
is  a  severe  tax  upon  the  patience  and  ingenuity  of  the  physician 
and  the  nurse.  When  the  insidious  effects  of  the  drug  upon 
the  mental  and  physical  state  of  the  patient  are  remembered,  it 
becomes  clear  that  a  cure  cannot  be  accomplished  except  after 
a  long  time.  When  large  quantities  of  the  drug  have  been 
taken  daily,  in  private  practice  the  gradual,  and  not  the  sudden, 
withdrawal  is  indicated,  since  the  latter  is  apt  to  be  accompanied 
by  severe  and  at  times  dangerous  effects.  If,  however,  it  is 
possible  to  place  the  patient  in  a  hospital  before  beginning  the 
treatment  the  morphin  may  be  stopped  at  once.32  Isolation  is 
absolutely  necessary.  If  he  remains  at  home,  the  patient  must 
be  secluded,  if  possible,  from  all  members  of  his  family  and 
from  his  friends  and  placed  in  charge  of  thoroughly  competent 
nurses  who  must  be  fully  impressed  with  the  importance  of  the 
fact  that  such  individuals  will  resort  to  every  possible  subter- 
fuge in  order  to  obtain  the  drug.  In  what  may  be  termed  the 
expectant  treatment,  while  the  drug  is  being  gradually  with- 
drawn, the  various  symptoms  must  be  dealt  with  as  they  arise. 
A  milk  diet — small  quantities  being  given  every  two  hours — 
is  at  first  preferable.     If  the  milk  is  not  well  borne  by  the 


32  Halleck,  M.  S. :    Cases  of  Morphinism  in  which  the  drug  was  im- 
mediately withdrawn.     Medical  Record,  1903,  vol.  lxiii,  No.  15,  p.  572. 


MORPHINISM  321 

stomach,  broths,  albumen,  and  plain  soups  may  be  substituted. 
The  bowels  must  be  carefully  regulated  and  any  attacks  of 
diarrhoea,  which  may  occur,  must  be  checked  as  soon  as  pos- 
sible, inasmuch  as  they  soon  bring  about  a  weakening  of  the 
patient.  All  forms  of  stimulants  except  in  emergencies,  such  as 
weakness  or  irregularity  of  the  heart  or  an  imminent  collapse, 
are  contraindicated.  In  the  very  severe  cases,  however,  caffein, 
digitalis,  whiskey,  and  strychnin  are  sometimes  beneficial.  The 
restlessness  and  delirium  may  be  combated  by  the  warm  pack 
or  the  continuous  bath  given  with  great  care.  Occasionally  the 
administration  of  sedatives  becomes  necessary,  but  these  should 
be  withdrawn  at  the  earliest  possible  moment.  As  the  nutrition 
of  the  skin  is  generally  seriously  impaired,  care  should  be  taken 
that  bed-sores  do  not  develop. 

During  the  early  stages  of  the  treatment,  particularly  in 
the  severer  cases,  in  addition  to  isolation  and  rest  in  bed,  forced 
feeding  becomes  imperative.  Gradually,  as  the  patients  gain 
mentally  as  well  as  physically,  they  may  be  allowed  to  get  up, 
at  first  for  short  periods  of  time.  At  this  period  the  cold  pack, 
cold  sprays,  massage,  or  gymnastics  under  medical  supervision 
are  of  great  advantage.  As  soon  as  the  patient  is  able  to  go 
about,  it  is  desirable  that  he  should  be  sent  to  some  small  sani- 
tarium in  the  country,  where  he  may  have  a  restful  life,  good 
food,  plenty  of  fresh  air,  and  strict  medical  supervision.  In 
this  connection,  however,  a  careful  choice  is  necessary,  since 
not  every  institution  which  receives  these  patients  supplies  suffi- 
cient medical  care,  and  in  some  cases  the  environment  of  the 
patient  is  anything  but  satisfactory.  Under  no  condition  should 
the  physician  permit  a  return  to  the  ordinary  surroundings  and 
avocation  until  a  very  considerable  period  of  time  has  elapsed 
after  the  giving  up  of  the  habit.  If  it  is  necessary  that  the 
patient  should  return  to  a  life  where  there  is  mental  and  physi- 
cal strain,  to  speak  of  a  complete  recovery  until  at  least  a  year 
has  elapsed  is  utterly  ridiculous.  If,  however,  it  is  possible  to 
surround  him  with  conditions  which  will  allow  him  to  lead  a 
healthy  life,  in  an  environment  which  does  not  impose  too  great 
a  tax  upon  his  physical  or  mental  reserve  force,  he  may  be  per- 


322 


PSYCHIATRY 


mitted  to  do  so  at  an  earlier  time  provided  it  is  possible  to  con- 
tinue the  medical  supervision  of  the  case. 

Recently  the  administration  of  hyoscin  has  been  highly 
recommended  in  the  treatment  of  morphinism,  but  even  small 
doses  cause  alarming  symptoms  in  some  patients.33  Camphor 
has  also  been  given  as  a  substitute  with  varying  results.34  Liv- 
ingston 35  recommends  ergot  very  highly  in  the  treatment  of 
alcoholism  and  morphinism. 

Cocainism. — The  conditions  which  lead  to  the  develop- 
ment of  the  cocain  habit  are  as  complex  and  varied  as  those 
which  give  rise  to  morphinism.  When  cocain  was  first  intro- 
duced, it  was  sometimes  prescribed  as  a  remedy  for  the  mor- 
phin  habit,  and  the  result  in  a  large  number  of  cases  was  that 
the  patient  gave  up  the  former  to  acquire  the  latter  vice.  As 
a  rule,  the  cocainism  is  not  generally  accompanied  in  the 
early  stages  with  the  pronounced  symptoms  that  mark  the 
addiction  to  morphin.  We  do,  however,  meet  with  restless- 
ness, irritability,  a  certain  degree  of  insomnia,  loss  of  appetite, 
and,  if  the  habit  is  persisted  in  for  any  length  of  time,  the  indi- 
vidual may  become  subject  to  choreiform  movements,  anomal- 
ous emotional  states  characterized  by  outbreaks  of  temper  and, 
in  the  severer  cases,  transitory  delirious  states  with  auditory 
and  visual  hallucinations.  On  the  other  hand,  if  addiction  to 
the  drug  continues,  the  manifestations  increase  in  intensity  with 
more  rapidity  than  in  the  morphin  habit. 

The  physical  symptoms  accompanying  the  mental  disturb- 
ances usually  consist  in  marked  tremor,  sometimes  great  pallor, 
profuse  sweating,  cold  extremities,  and  most  commonly  a  rapid 
and  small  pulse.  The  pupils  are  usually  dilated.  At  times  these 
patients  are  subject  to  attacks  of  syncope  and  in  some  instances 


33  Pettey  :  Drug  Habit.  Med.  News,  1902.  Crothers,  T.  D. :  Hyoscine 
in  the  Treatment  of  Morphinism.  The  Quarterly  Journal  of  Inebriety, 
1903,  vol.  xxv,  No.  3,  July.  Rosenberger,  C. :  The  Hyoscine  Treatment 
of  a  Morphine  Habitue.    The  Medical  News,  November  29,  1902. 

34  Erlenmeyer :  Therapeut.  Monatsh.,  1903,  Februar.  Hofmann: 
Therapeut.  Monatsh.,  1903,  April. 

85  Medical  News,  March  5,  1904. 


BROMISM 


323 


epileptiform  convulsions  supervene.  Confirmed  habitues,  when 
under  the  immediate  influence  of  the  drug,  seem  to  be  imper- 
vious to  any  sense  of  fatigue  and  to  have  a  craving  for  the  dis- 
charge of  nervous  energy,  which  is  exhibited  both  mentally  and 
physically.  Not  uncommonly  we  meet  with  various  disturbances 
of  sensation,  generally  anaesthesias,  although  paresthesias  and 
hyperesthesias  are  not  rare.  At  times,  in  addition  to  the  audi- 
tory and  visual  hallucinations,  to  which  reference  has  been 
made,  the  patients  are  subject  to  psychomotor  hallucinations 
and  curious  disturbances  in  the  organic  sensations,  so  that  they 
feel  as  if  they  were  floating  in  the  air,  balancing  on  the  edge 
of  a  precipice,  and  so  on. 

As  regards  treatment,  what  has  already  been  said  in  regard 
to  morphinism  holds  good  with  appropriate  modifications  for 
the  cocain  habit. 

Bromism. — Not  infrequently  the  alienist  has  opportunities 
of  observing  the  symptoms  produced  as  the  result  of  the  ex- 
cessive administration  of  some  form  of  the  bromides.  In  fact, 
the  somewhat  reckless  manner  in  which  these  drugs  are  given  in 
all  forms  of  nervous  excitement  or  depression  makes  this  group 
of  cases  comparatively  large.  As  a  rule,  the  mental  disturb- 
ances are  characterized  by  a  delay  in  the  elaboration  of  incident 
stimuli  and  an  impairment  of  all  of  the  more  complicated  voli- 
tional acts.  When  the  symptoms  are  pronounced,  the  patient 
often  speaks  in  a  low,  monotonous  tone,  only  replying  to  ques- 
tions after  a  considerable  delay.  When  asked  to  exert  himself 
in  any  way,  he  shows  a  marked  inhibition  in  connection  with 
the  execution  of  the  muscular  movements.  At  times  these  more 
elementary  symptoms  are  complicated  by  marked  defects  in 
memory  amounting  at  times  to  more  or  less  complete  disorien- 
tation, confusion,  sleepiness,  or  stupor,  while  associated  with 
these  are  certain  physical  symptoms,  such  as  vertigo,  ataxia, 
epileptiform  attacks,  and  various  signs  of  disturbances  in  the 
gastro-intestinal  tract. 

Tobacco  Intoxication. — At  the  present  time  we  under- 
stand very  little  about  the  nature  of  tobacco  poisoning,  and  it  is 
probable  that  many  of  the  deleterious  effects  attributed  to  nico- 


324  PSYCHIATRY 

tin  are  due  to  one  or  more  of  the  various  derivatives  of  the 
plant.  Although  it  is  frequently  stated  in  text-books  that  the 
excessive  use  of  tobacco  may  give  rise  to  marked  mental  dis- 
turbances, such  as  delirious  states  and  subacute  or  chronic  hal- 
lucinatory paranoiic  conditions,  it  is  doubtful  whether  the  drug 
is  ever  the  sole  cause  of  a  definite  protracted  mental  aberration. 
The  conditions  which  result  from  the  excessive  use  of  tobacco 
in  any  form  are  well  known.  They  vary  in  different  individuals 
from  mild  gastro-intestinal  disturbances  to  more  severe  symp- 
toms, with  loss  of  appetite,  nausea,  vomiting,  associated  with 
disturbances  in  the  circulation,  such  as  a  weak  and  rapid,  irreg- 
ular, or  intermittent  heart.  Individual  idiosyncrasies  for  to- 
bacco are  not  uncommon.  In  some  cases  the  smoking  of  3 
single  cigar  renders  certain  people  markedly  depressed  mentally 
for  several  hours. 

Ergotism. — The  chronic  intoxication  the  result  of  the 
ingestion  of  ergot,  although  observed  in  Europe,  particularly 
in  South  Germany  and  Italy,  is  practically  unknown  in  the 
United  States.  The  symptoms  induced  by  continued  doses  of 
this  poison  may  resemble  those  encountered  in  tabo-paresis. 

Lead  Poisoning;  Saturnism. — As  long  ago  as  1771, 
Dehane  36  called  attention  to  the  fact  that  mental  disturbances 
sometimes  appear  in  individuals  who  have  been  poisoned  by 
lead.  The  first  definite  attempt,  however,  to  establish  a  causal 
relationship  between  the  disturbances  in  nervous  functions  and 
lead  intoxication  was  made  by  Tanquerel  des  Planches.37 
Since  that  time  investigators  have  discovered  many  interesting 
facts  which  have  an  important  bearing  on  this  question.  The 
peripheral  forms  of  paralysis  will  not  be  discussed  here.  The 
alienist  is  more  particularly  interested  in  the  mental  disturb- 
ances, which  are  generally  spoken  of  under  the  head  of  lead 
encephalopathy  and  in  the  main  present  certain  characteristics 
in  common.    Sometimes  the  mental  symptoms  are  ushered  in  by 


36  Ratio  Medendi.     Paris,  1771. 

37  Traite  des  Maladies  du  Plomb  cm  Saturnisme.     Paris,  1840. 


SATURNISM  32- 

epileptiform  attacks    (Judd,38  Oliver39).     In  some  instances 
the  epileptiform  attacks  are  followed  by  apoplectiform  seizures, 
which  may  have  a  rapidly  fatal  ending.  Another  group  of  cases 
belonging  to  the  delirious  form  are  characterized  by  a  more  or 
less  acute  onset.    The  prodromal  symptoms  are  apt  to  be  those 
usually  associated  with  lead  poisoning— constipation,  lead  colic, 
etc.     Later  the  patient  begins  to  complain  of  severe  headache! 
loss  of  sleep,  disturbances  of  vision,  and  still  later  of  more  or 
less  active  hallucinations.      In   the  cases   characterized   by   a 
slower  course  paresthesias  precede  the  more  acute  period  of  de- 
lirium.   During  these  attacks  periods  of  profound  coma  may  or 
may  not  occur.     Another  form  of  lead  paralysis  is  represented 
in  the  types  either  associated  or  identical  with  cases  of  dementia 
paralytica. 

The  manner  in  which  the  poison  acts  has  not  as  yet  been 
satisfactorily  explained,  although  a  variety  of  hypotheses  have 
been  advanced.  By  some  investigators  it  is  supposed  that  the 
lead  produces  a  true  cerebral  anaemia  giving  rise  to  headaches 
vertigo,  sensorial  troubles,  delirium,  etc.  Jaccoud  believed  that 
this  poison  showed  a  particular  affinity  for  the  brain.  The 
general  consensus  of  opinion  favors  the  view  that  the  lead  may 
simply  be  regarded  as  an  inciting  factor,  generally  in  those  who 
have  already  shown  some  predisposition  to  alienation. 

38  Judd,  W.  R.:    A  Case  of  Lead  Encephalopathy.     Brit.  Med.  Tourn 
1904,  April  16. 

39  Clifford  Allbutt's  System  of  Medicine,  vol.  ii,  p.  988. 


CHAPTER    XII 

PSYCHOSES  ASSOCIATED  WITH  IMPERFECT  FUNCTIONING  OF 
THE    THYROID    GLAND  1 

The  mental  disturbances  associated  with  disordered  func- 
tions of  the  thyroid  may  be  divided  into  two  groups :  ( I ) 
Those  due  to  diminished  function, — myxcedema  and  cretinism. 
(2)   Those  due  to  hyperf unction, — exophthalmic  goitre. 

Myxcedema. — Gull  in  1873  ^rst  called  attention  to  cer- 
tain physical  and  mental  symptoms  occurring  in  women  in 
association  with  disturbances  of  function  in  the  thyroid  gland. 
These  observations  were  extended  to  male  patients  by  Ord, 
who  proposed  the  term  myxcedema  to  designate  this  condition. 
Several  years  later  Charcot  and  Ballet  added  greatly  to  the 
clinical  knowledge  of  this  disorder;  but  it  was  not  until  the 
operative  experience  of  Reverdin  in  1882,2  of  Kocher  in  1883, 
and  the  important  experimental  work  upon  animals  of  Scruff, 
Horsley,  and  others  appeared,  that  its  true  nature  was  made 
clear.  From  the  facts  gathered  from  these  various  sources  it 
became  evident  that  any  marked  deficiency  in  the  functions 
of  the  thyroid  may  give  rise  to  symptoms  of  myxcedema.  All 
these  studies  were  verified  and  extended  by  further  experience 
with  cases  of  operative  myxoedema  or  the  cachexia  strumi- 
priva. 

The  physical  symptoms  of  myxcedema  need  not  be  dwelt 
upon  here  at  length,  as  they  are  fully  described  in  the  various 

1  Church  and  Peterson :  Myxoedema.  Nervous  and  Mental  Diseases. 
Philadelphia,  New  York,  and  London,  1903.  Roubinovitch,  J. :  Troubles 
mentaux  par  insuffisance  thyro'idienne.  Traite  de  la  pathol.  mentale. 
Paris,  1903.  Osier,  W. :  Practice  of  Medicine.  Fifth  Edition.  New  York, 
1903.  Also  Sporadic  Cretinism  in  America.  Trans,  of  the  Congress  of 
American  Physicians  and  Surgeons,  vol.  iv. 

2  In  1867  Sick  had  called  attention  to  a  form  of  psychic  degeneracy 
occurring  in  a  ten-year-old  boy  following  operation  on  the  thyroid. 

326 


MYXEDEMATOUS    INSANITY 


327 


text-books  on  clinical  medicine.  Peculiar  changes  in  the  skin 
early  attract  attention.  A  mucoid  infiltration  makes  its  ap- 
pearance in  the  integument  of  the  face,  extremities,  abdomen, 
nose,  ears,  and  eyelids,  as  well  as  in  certain  other  localities. 
There  are  well-marked  changes  in  the  hair,  teeth,  and  nails, 
as  well  as  in  the  buccal,  lingual,  and  pharyngeal  mucous  mem- 
branes. Glandular  activity  is  interfered  with.  The  thyroid 
is  diminished  in  size  in  most  of  the  cases,  although  it  is  occa- 
sionally larger  than  normal.  Sensory  disturbances  also  occur, 
and  areas  where  the  infiltration  is  marked  are  apt  to  be  anaes- 
thetic or  hyperaesthetic.  The  pulse  is  irregular  and  weak. 
The  patient  soon  presents  the  peculiar  cachectic  appearance 
more  or  less  characteristic  of  the  disease. 

Myxedematous  Alienation. — Mental  anomalies  are  to  be 
found  in  nearly  all  cases  of  myxcedema  and  are  chiefly  charac- 
terized by  marked  impairment  in  connected  thinking.  Among 
the  milder  forms  of  mental  defect  usually  noticeable  are  diffi- 
culty in  thinking,  apathy,  memory  defects,  and  a  tendency  to 
excessive  drowsiness.  As  a  rule,  the  patients  become  indiffer- 
ent to  their  surroundings,  do  not  respond  to  the  action  of  nor- 
mal stimuli,  and  as  the  disease  advances  show  great  impair- 
ment of  the  power  of  recollection  as  well  as  in  the  elaboration 
and  working  up  of  new  stimuli.  Wolseley 3  maintains  that 
in  cases  of  myxcedema  the*  spontaneous  attention  or  instinctive 
selection  of  some  stimuli  in  preference  to  others  is  impaired. 
Contrary  to  the  general  opinion  entertained  by  physicians, 
this  observer  thinks  that  the  retentiveness  of  memory  is  well 
preserved  while  its  impressionability  is  diminished.  The  chief 
characteristic  of  the  mental  state  is  the  retardation  of  thought 
without  any  impairment  in  judgment.  If  the  attention  of  the 
patient  is  once  aroused  and  sustained,  there  is  no  evident  dis- 
sociation of  the  mental  processes,  while  the  diminution  in  the 
volitional  impulses  is  the  cause  of  the  lack  of  initiative  as  well 


3  Wolseley,  Lewis :    The  Mental  State  in  Myxoedema.     Lancet,  April 
23,  1904- 


328  PSYCHIATRY 

as  of  the  striking  immobility  of  face  and  body  so  characteristic 
of  the  disease.  In  a  comparatively  large  number  of  cases  hal- 
lucinations and  insane  ideas  of  varying  degrees  of  intensity 
may  be  present.  Pilcz  4  has  called  attention  to  the  fact  that 
the  mental  manifestations  at  times  are  dependent  upon  the 
myxcedema  and  are  then  symptoms  of  the  disease;  in  other 
instances  they  are  merely  the  expression  of  a  complicating 
psychosis.  That  different  types  of  alienation  may  compli- 
cate myxcedema  has  also  been  shown  by  numerous  authorities, 
particularly  Berkley,  and  for  this  reason  the  great  variety  of 
the  mental  symptoms  which  have  been  observed  during  the 
course  of  myxcedema  and  which  have  been  said  to  be  specific 
of  the  disease  is  open  to  doubt.  Nevertheless,  the  fact  that 
certain  types  of  insanity  occurring  during  the  course  of  myx- 
cedema recover  completely  after  the  administration  of  the  thy- 
roid extract  renders  it  in  the  highest  degree  probable  that 
a  specific  myxcedematous  insanity  exists,  and  therefore  not 
all  cases  are  to  be  regarded  merely  as  a  combination  of 
myxcedema  and  an  independent  psychosis.  Instances  of 
pronounced  myxcedematous  insanity  are  not  very  rare  and 
have  been  reported  by  a  large  number  of  clinicians.  Accord- 
ing to  Clouston,  the  primary  changes  are  delay  in  the  asso- 
ciational  processes,  vague  suspiciousness,  and  varying  degrees 
of  mental  depression.  In  some  ca'ses  a  period  of  euphoria 
or  maniacal  exaltation  intervenes,  while  some  writers  have 
reported  symptoms  of  negativism,  verbigeration,  and  various 
forms  of  dementia.  These  last  must  be  accepted  with  great 
caution,  as  the  further  histories  of  the  cases  are  not  given 
and  their  occurrence  would  suggest  a  possible  dementia  prsecox 
complicating  myxcedema. 

A  convenient  clinical  classification  into  two  categories 
may  be  made.  In  the  first,  progressive  somnolence,  torpor, 
intellectual   defects,    and   not   infrequently   various    forms    of 


4  Pilcz,  Alexander :  Zur  Frage  des  myxodematosen  Irreseins  und  der 
Schilddriisentherapie  bei  Psychosen  uberhaupt.  Jahrb.  f.  Psych,  u.  Neurol., 
1901,  Bd.  xx,  S.  77. 


CRETINISM 


329 


convulsions  and  coma,  ending  in  death,  form  the  clinical  pic- 
ture. To  the  second  belong  hallucinations  of  the  senses,  par- 
ticularly anomalies  of  the  various  organic  sensations,  as  well 
as  disturbances  of  taste,  smell,  and  hearing.  The  attacks  of 
mental  depression  may  alternate  with  those  of  maniacal  ex- 
citement, and,  in  addition  to  these,  states  of  anxiety  associated 
with  visual  hallucinations  of  a  very  vivid  and  terrifying  char- 
acter have  been  noted.  One  instance  has  been  reported  in 
which  there  were  symptoms  of  marked  mental  depression  with 
hypochondriasis  and  ideas  of  persecution.  The  majority  of 
cases  in  which  periods  of  exaltation  and  depression  occur  not 
improbably  are  complicated  by  a  manic-depressive  insanity. 
In  many  of  these  cases  found  in  the  literature  the  records 
are  too  incomplete  to  justify  a  positive  declaration  as  to 
whether  the  psychosis  was  an  expression  of  the  primary  dis- 
ease or  merely  represented  a  combination  of  two  totally  dif- 
ferent processes.  Unfortunately,  not  a  few  patients  have  been 
under  observation  only  in  the  wards  of  a  general  hospital, 
whence,  upon  the  subsidence  of  all  symptoms,  they  have  been 
discharged  and  reported  as  cured ;  but,  on  account  of  the  lack 
of  further  information,  it  is  impossible  to  say  that  no  recur- 
rence of  the  mental  trouble  occurred  later  on. 

In  the  treatment  of  myxcedema  the  thyroid  extract  is, 
as  is  well  known,  a  specific.  Various  preparations  may  be  ad- 
ministered. Concerning  the  relative  merits  of  these  the  reader 
is  referred  to  the  text-books  on  general  medicine.  In  regard 
to  the  treatment  of  the  special  mental  symptoms  to  which  ref- 
erence has  been  made,  the  indications  are  the  same  as  those 
laid  down  for  similar  conditions.     (See  Chapter  V.) 

Cretinism. — By  some  the  word  cretinism  is  said  to  have 
been  derived  from  Chretien,  Christian,  and  referred  to  the 
supposed  inability  of  these  imbeciles  to  commit  sin.  A  more 
probable  derivation  is  from  cretira  (creatura),  a  term  used 
to  designate  an  individual  whose  physical  impairment  was  such 
as  to  make  him  an  object  of  pity.5     Cretinism  is  more  or  less 

B  Ackermann :     Ueber    die    Kretinen,    eine   besondere    Menschenart    in 
den  Alpen.     Gotha,  1790. 


33Q 


PSYCHIATRY 


endemic  in  parts  of  Switzerland,  Italy,  France,  Sweden,  Great 
Britain,  and  in  a  few  places  in  North  America  (Minnesota, 
Ontario).     Sporadic  cases  are  met  with  in  all  countries.6 

This  congenital  condition  is  characterized  by  mental  and 
physical  anomalies  which  in  their  totality  alone  are  distinctive. 
Prominent  among  the  former  is  the  general  impairment  in 
all  the  mental  faculties,  and  among  the  latter  are  the  changes 
in  the  skeleton  and  the  skin  and  deficiencies  in  the  sexual  appa- 
ratus. All  these  changes  are  more  or  less  directly  related  to 
the  disturbances  in  the  function  of  the  thyroid  gland.  The 
operative  causes  are  largely  endemic. 

Physical  Symptoms. — Among  those  which  have  received 
the  most  notice  from  clinicians  are  the  defects  in  the  thyroid 
gland.  In  many  cases,  however,  it  is  extremely  difficult  to  tell 
from  palpation  whether  there  is  an  actual  change  in  the  struct- 
ure of  this  organ.  This  is  largely  due  to  the  fact  that  it 
develops  behind  the  sternum  and  therefore  can  be  examined 
only  with  great  difficulty.  The  general  consensus  of  opinion  is 
that  only  a  certain  proportion  of  these  defectives  show  any 
abnormalities  of  the  thyroid.  Thus,  out  of  3600  cretins  ex- 
amined in  Lombardy  only  1125  showed  an  enlargement. 

Among  the  most  striking  features  are  the  remarkable  de- 
fects in  the  development  of  the  bony  skeleton.  As  a  rule,  these 
are  not  noticed  at  birth,  but  become  apparent  only  after  the 
lapse  of  several  months.  The  disproportionateness  in  develop- 
ment of  the  skeleton  is  not  nearly  as  marked  as  in  the  cases  of 
idiots,  although  sometimes  the  abnormality  of  the  -skull  is  at 
once  noticeable.  Cretins  are  met  with  in  whom  the  skull  seems 
to  be  proportionately  smaller.  The  delay  in  the  ossification 
and  the  persistence  of  the  cartilaginous  epiphyses  in  the  bones 
are  frequently  so  marked  that  the  limb  of  an  adult  may  re- 
semble that  of  an  infant  of  one  or  twro  years.  The  physiog- 
nomy of  these  patients  is  very  striking,  and  here  again  the 
changes  in  the  bones  are  very  apparent.     The  nose  is  usually 


8  Weygandt,   W. :     Der   heutige    Stand   der   Lehre   vom    Kretinismus. 
Halle  a/  S.,  1904. 


CRETINISM 


331 


flat  and  broad,  the  orbital  cavities  are  far  apart,  and  the  jaws 
protrude.  The  skin  is  less  affected  than  in  cases  of  myxcedema, 
and  this  fact  has  led  certain  observers  to  believe  that  the  ab- 
sence of  myxcedematous  changes  was  specific  of  the  typical 
cretins.  More  careful  investigation,  however,  has  failed  to 
substantiate  this  view.  The  hair  is  somewhat  sparse  and  falls 
out  easily.  The  nails  are  defective  and,  as  in  myxcedema,  there 
is  considerable  interference  with  the  function  of  the  sweat- 
glands.  The  surface  temperature  is  apt  to  be  below  that  of 
the  normal  individual.  The  skin  has  a  wrinkled  appearance, 
so  that  even  when  quite  young  cretins  may  look  like  old  peo- 
ple. Various  anomalies  are  found  in  connection  with  the  mus- 
cles and  their  mechanical  irritability  is  said  to  be  increased. 
As  would  be  expected,  the  internal  organs  are  nearly  always 
affected,  particularly  the  heart  and  lungs.  Anomalies  occur- 
ring in  the  sexual  organs  are  common.  In  some  cases  even 
after  the  thirtieth  year  no  development  of  the  genitals  has 
taken  place.  In  women  the  breasts  are  apt  to  be  poorly  devel- 
oped and  pigmentation  as  well  as  glandular  tissue  is  almost 
completely  absent. 

Mental  Symptoms. — The  primary  perceptions  are  often 
impaired.  This  impairment  may  or  may  not  be  due  to  local 
causes.  Thus,  defects  of  hearing  are  not  infrequently  due  to 
the  existence  of  a  catarrh  or  enlarged  tonsils,  and  those  con- 
nected with  taste  and  smell  to  pathological  conditions  of  the 
mucous  membranes.  The  disturbances  in  the  associative  mem- 
ory, as  well  as  in  the  more  complicated  mental  processes,  vary 
greatly  according  to  the  individual  case.  As  yet  a  satisfactory 
grouping  of  the  cases  is  impossible,  and  the  best  is  probably 
an  empirical  division  into  the  apathetic  or  anergetic  and  the 
excitable  or  erethic  form.  All  degrees  from  the  severest  to 
the  mildest  type  are  encountered.  In  the  worst  cases  the 
individual  never  develops  mentally  beyond  the  condition  be- 
longing to  earliest  infancy.  There  is  a  marked  inhibition  of 
all  the  psychical  activities,  of  the  attention,  the  power  of  re- 
taining and  elaborating  impressions,  etc.  Sometimes  there  is 
great  interference  with  the  understanding  of  speech,  and  the 


332 


PSYCHIATRY 


patients  are  capable  of  learning  the  meaning  of  only  a  few 
of  the  simplest  words  and  signs.  The  existence  of  such  indi- 
viduals, as  in  the  case  of  the  worst  type  of  idiots,  is  largely 
vegetative.  Only  occasionally  are  inarticulate  sounds  produced. 
In  rare  instances  the  involuntary  rhythmic  movements  some- 
times noted  in  idiots  are  encountered. 

In  milder  cases  the  individual  reaches  the  stage  when  he 
is  able  to  a  certain  extent  to  appreciate  his  surroundings  and 
is  capable  of  being  taught  to  feed  and  dress  himself,  but  devel- 
opment further  than  this  does  not  take  place.  Some  difficulty 
in  articulation  is  present  in  nearly  all  the  cases.  Certain  indi- 
viduals show  sufficient  mental  capacity  to  go  to  special  schools 
where  they  are  able  to  acquire  the  rudiments  of  an  education. 
The  acquisition  of  manual  dexterity  is  usually  easier  than  of 
knowledge  acquired  from  books. 

According  to  Weygandt,  the  patients  may  be  divided  into : 
( i )  dwarf  cretins  and  those  of  the  infantile  type,  in  which  the 
skeletal  and  mental  development  do  not  advance  beyond  the 
stage  of  a  child  of  three  or  four  years;  (2)  half-cretins,  who 
correspond  to  the  anergetic  type  but  are  still  capable  of  being 
educated;  the  dwarf  features  are  marked  and,  as  a  rule,  the 
patients  average  about  four  feet  in  height;  (3)  the  cretinoids, 
who  still  show  the  habitus,  the  lack  of  development,  the  cretin 
physiognomy,  and  the  changes  in  the  skin,  as  well  as  the  men- 
tal insufficiency.  In  all  these  cases  it  must  be  remembered  that 
the  disturbances  which  occur  in  the  various  organs  are  not 
always  of  equal  degree  of  intensity,  so  that  the  anomalies  in  the 
skeleton,  skin,  and  central  nervous  system  may  show  consid- 
erable variations.7 

Pathology. — The  work  of  Langhans 8  undoubtedly 
formed  the  basis  for  many  later  investigations  into  the  patho- 
logical anatomy  of  cretinism.    In  some  cases  the  thyroid  shows 

7  Weygandt,  W. :  Ueber  Virchow's  Cretinentheorie.  Neurol.  Cen- 
tralbl.,  Nr.  7-8,  1904. 

8  Anatomische  Beitrage  zur  Kenntniss  der  Cretinen  (Knochen,  Ge- 
schlechtsdrusen,  Muskeln  und  Muskelspindeln  nebst  Bemerkungen  uber 
die  Bedeutung  der  letzteren).    Virchow's  Archiv,  1897,  Bd.  cxlix,  S.  155. 


EXOPHTHALMIC    GOITRE 


333 


marked  atrophy  of  its  epithelium,  while  in  one  instance  there 
was  a  decided  hypertrophy  of  one  portion.  Tumors  have  been 
reported  situated  to  one  side  of  the  trachea.  The  medulla  of 
many  of  the  bones  resembles  that  found  during  infancy.  The 
ovaries  show  cystic  degeneration.  The  testicles  are  atrophic. 
According  to  Hofmeister,  in  animals  whose  thyroid  has  been 
removed  no  spermatozoa  are  found.  The  myxcedematous 
changes  have  already  been  described.  The  heart  and  lungs 
show  changes.  The  spleen,  liver,  and  kidneys  are  also  abnor- 
mal. In  the  cerebral  cortex,  in  specimens  prepared  with  the 
Nissl  stain  the  nerve-cells  seemed  to  be  small  and  did  not  stain 
deeply.  The  apical  processes  showed  considerable  change, 
being  somewhat  attenuated  and  visible  for  long  distances.  All 
the  various  theories  entertained  regarding  the  origin  of  cre- 
tinism cannot  be  mentioned  here.  According  to  one  view,  it 
is  not  at  all  improbable  that  through  the  drinking-water  some 
deleterious  organism  is  introduced  into  the  system  which  has 
a  particular  affinity  for  the  thyroid  gland. 

As  regards  the  differential  diagnosis,  it  is  necessary  to  dis- 
tinguish between  cretins,  individuals  suffering  from  other 
diseases  of  the  thyroid,  cases  of  dwarfism  due  to  other  causes, 
and  congenital  idiots  or  feeble-minded  persons.  In  this  country 
this  differentiation  becomes  unnecessary,  as  only  the  sporadic 
cases  of  cretinism  ever  develop. 

In  the  treatment,  removal  from  unhygienic  surroundings 
and  change  in  the  water-supply  are  important.  The  brilliant 
results  obtained  from  the  administration  of  thyroid  extract  are 
too  well  known  to  need  detailed  mention  here. 

Mental  Disorders  associated  with  Hyperfunction 
of  the  Gland:  Exophthalmic  Goitre,  Graves'  Dis- 
ease, Basedow's  Disease. — It  has  long  been  recognized  that 
mental  disturbances  are  apt  to  occur  during  exophthalmic 
goitre  (Basedow,  1840).  The  milder  forms  consist  in  emo- 
tional instability,  attacks  of  more  or  less  depression  or  ex- 
citement with  accompanying  states  of  apprehensiveness  and 
mild  phobias.  The  attention  is  also  markedly  disturbed,  and, 
on  account  of  the  nervousness,  it  is  apparently  impossible  for 


334 


PSYCHIATRY 


these  patients  to  concentrate  their  minds  long  upon  any  one 
subject.  Another  group  of  cases  is  met  with  in  which  the 
symptoms  are  episodic  in  character,  states  of  depression  or 
excitement  alternating;  and  during  these  periods  obsessions, 
impulses,  and  phobias  may  develop.  The  hallucinations  that 
have  been  reported  in  cases  are,  as  a  rule,  visual  in  character 
and  generally  of  a  disturbing  or  terrifying  nature.  Ballet 9 
recorded  cases  in  which  the  visual  were  followed  by  audi- 
tory hallucinations  and  eventually  systematized  persecutory 
ideas  developed.  Statistics  go  to  show  that,  although  periods  of 
depression  may  occur,  the  maniacal  symptoms  seem  to  be  much 
more  frequent.  Jacobs  10  was  able  to  rind  the  records  of  ten 
cases  in  which  an  acute  mania  terminating  fatally  complicated 
the  course  of  Graves'  disease.  Hirschl lx  extracted  from  the 
literature — from  1862  to  the  present  date — 43  cases  of  in- 
sanity complicating  Basedow's  disease.  Of  these  the  ma- 
jority showed  maniacal  symptoms,  only  6  recovered  from 
the  alienation,  while  18  of  the  patients  died.  Certain  French 
writers,  however,  particularly  Dutil,  hold  that  the  occur- 
rence of  these  psychoses  in  the  course  of  goitre  is  somewhat 
commoner  than  the  above  statement  would  lead  us  to  infer. 
It  should  not,  however,  be  forgotten  that  in  a  certain  propor- 
tion they  are  in  reality  phases  of  some  independent  psychosis, 
so  that  after  the  cases  of  alcoholism,  manic-depressive  insanity, 
and  dementia  prsecox  have  been  eliminated  there  remains  a 
comparatively  small  group  which  definitely  belongs  to  this  cate- 
gory. Whether  we  are  at  present  justified  in  classifying  these 
forms  of  alienation  as  in  a  measure  characteristic  of  the  dis- 
turbances of  the  thyroid  gland  we  are  unable  to  say.  The 
question  needs  to  be  more  fully  investigated,  and,  unfortu- 
nately, the  majority  of  records  in  the  literature  are  too  in- 
complete to  warrant  a  positive  conclusion. 

'  Des  idees  de  persecution  dans  le  goitre  exophthalmique.  Soc.  med. 
des  hop.,  1800. 

10 Jacobs,  Henry  Barton:  The  Am.  Journ.  Insan.,  vol.  lv,  No.  I, 
1898. 

11  Krafft-Ebing :    Lehrbuch  der  Psych.,  Stuttgart,  1903. 


EXOPHTHALMIC    GOITRE 


335 


The  treatment  is  largely  symptomatic.  As  a  rule,  the  pa- 
tients if  they  have  become  at  all  excited  should  be  at  once 
transferred  to  a  hospital.  There  they  can  be  kept  in  bed  on 
a  fluid  diet.  The  administration  of  sodium  phosphate,  as  rec- 
ommended by  Mobius  and  others,  may  be  tried,  as  well  as  the 
effects  of  belladonna.  The  thyroid  extract  has  been  frequently 
given  in  these  cases,  but,  although  its  use  has  occasionally 
seemed  to  be  beneficial,  it  usually  makes  the  condition  worse. 
As  a  rule,  during  the  periods  of  marked  depression  or  excite- 
ment the  patient  is  much  better  off  in  bed,  and  the  diet  should 
be  restricted  to  nutritious  and  easily  digested  forms  of  food. 
The  bowels  should  be  carefully  regulated.  Warm  packs  or 
prolonged  baths  are  often  efficacious. 


CHAPTER    XIII 

THE    MANIC-DEPRESSIVE    GROUP  * 

For  a  long  time  alienists  have  recognized  the  fact  that 
there  are  psychoses  characterized  by  maniacal  outbreaks  re- 
curring with  well-marked  periodicity  and  broken  by  inter- 
vening lucid  intervals.  Moreover,  clinical  experience  has 
shown  that  patients  afflicted  with  melancholia  later  in  the 
course  of  this  disease  not  infrequently  develop  maniacal  symp- 
toms. But  although  these  two  phenomena  have  been  recog- 
nized as  belonging  to  a  large  number  of  cases  of  alienation, 
the  interpretations  of  their  clinical  significance  have  not  always 
been  in  accord.2  The  older  clinicians  were  inclined  to  attrib- 
ute too  much  importance  to  the  mere  periodicity  which  char- 
acterized the  return  of  certain  psychoses,  and  even  recently 
Hitzig,  Jolly,  and  Pilcz  have  maintained  that  for  practical 
reasons  in  a  number  of  forms  of  insanity  it  is  still  necessary 
to  consider  this  as  the  most  distinctive  element  in  their  symp- 
tomatology. But  gradually  alienists  are  awakening  to  an 
appreciation  of  the  futility  of  attempting  to  establish  the  ex- 
istence of  a  disease  entity  upon  such  insufficient  grounds  as 
the  apparent  prominence  of  some  symptoms  and  the  conjec- 
tural unimportance  of  others,  and  are  learning  to  recognize 
that  to  attach  too  great  significance  to  the  more  periodic  re- 
currence of  individual  symptoms  is  equally  unscientific. 

A  new  epoch  began  in  1851  when  Falret 3  described  a 
periodic  mental  disturbance  which  he  designated  as  folic  cir- 
culaire.  Again,  after  Baillarger  and  Falret  in  1854,  indepen- 
dently of  each  other,  had  affirmed  that  the  so-called  circular 

1Hoch,    August:     Manic-Depressive    Insanity.      Reference    Handbook 
of  the  Medical  Sciences.     William  Wood  &  Co.,  New  York,  1902. 

2  Pilcz,  Alexander :    Die  periodischen  Geistesstorungen.     Jena,  1901. 

3  Gazette  des  Hopitaux,  1851. 

336 


MANIC-DEPRESSIVE    INSANITY  337 

insanity  was  a  disease  entity,  it  became  evident  that  hitherto 
sufficient  care  had  not  been  exercised  in  estimating  the  relative 
importance  of  all  factors  pertaining  to  the  etiology,  symptoma- 
tology, course,  prognosis,  and  termination  of  these  periods  of 
mental  aberration.  Moreover,  clinical  experience  had  demon- 
strated that  the  only  logical  and  scientific  method  of  studying 
disease  was  from  this  broader  and  far  more  comprehensive 
stand-point,  and,  as  a  result  of  these  changes  of  view,  less  stress 
was  laid  upon  individual  and  isolated  symptoms,  and  an  at- 
tempt was  made  to  give  to  each  event  in  the  disease  its  just 
valuation.  But  as  soon  as  the  truth  of  these  underlying  prin- 
ciples had  been  recognized  it  was  found  that  many  cases  of  so- 
called  simple  mania  or  melancholia,  as  well  as  of  the  mixed 
forms,  have  many  features  in  common,  and  on  closer  investi- 
gation it  also  became  apparent  that  pure  cases  of  mania  or 
melancholia  practically  never  occur.  Kraepelin,4  imbued  with 
these  ideas,  grouped  together  under  one  head  diseases  having 
a  common  symptomatology  with  a  certain  more  or  less  well- 
marked  tendency  to  recurrence  and  a  similar  outcome.  One  of 
the  fundamental  facts  that  served  to  direct  investigations  along 
this  line  was  that  in  many  forms  of  alienation  a  group  of 
symptoms  are  in  the  foreground  of  the  clinical  picture  which 
formerly  had  been  considered  specifically  characteristic  of  the 
so-called  circulary  insanities.  The  presence  of  a  marked  de- 
gree of  mental  deterioration  in  some  cases  and  its  absence  in 
others  was  also  an  important  consideration  that  influenced  the 
genesis  of  the  views  entertained  by  the  Heidelberg  school  in 
the  formulation  of  the  conceptions  of  the  manic-depressive 
insanity. 

Dementia  prsecox,  including  all  cases  in  which  there  is  a 
characteristic  mental  reduction,  affords  a  strong  contrast  to 
those  cases  in  which  the  symptoms  of  excitement  or  depression, 
with  a  tendency  to  recurrent  attacks,  may  occur,  but  without 
the  development  of  any  well-marked  specific  deterioration  of 
the  mental  faculties  during  the  lucid  intervals  or  as  a  terminal 

*  Lehrbuch  der  Psychiatrie,  1896. 
22 


338  PSYCHIATRY 

dementia.  The  expression  "  specific  deterioration"  must  be 
used  with  certain  qualifications.  In  the  present  state  of  our 
knowledge  we  are  not  justified  in  assuming  that  no  mental 
reduction  is  noticeable  in  those  cases  of  manic-depressive  in- 
sanity in  which  the  attacks  have  recurred  at  short  intervals 
or  have  lasted  for  long  periods  of  time.  Not  infrequently 
patients  pass  through  an  attack  of  alienation  that  in  all  par- 
ticulars, except  its  very  protracted  duration,  resembles  manic- 
depressive  insanity.  At  the  end  of  such  a  period,  when  the 
patients  are  discharged  "  recovered,"  we  are  frequently  un- 
able to  say  that  the  mental  faculties  are  quite  as  vigorous 
as  they  were  prior  to  the  onset  of  the  disease,  and  yet  if  a 
deterioration  does  exist  it  does  not  bear  any  resemblance  to 
that  occurring  in  cases  of  dementia  prsecox,  nor  does  it  have 
any  specific  signs  by  which  it  may  be  recognized.  In  some 
cases  neither  the  frequency  of  the  occurrence  nor  the  pro- 
tracted character  of  the  attacks  can  be  considered  responsible 
for  the  existing  mental  changes.  Cases  of  the  latter  group 
vary  greatly,  in  the  intensity  of  the  symptoms  as  well  as  in 
the  duration  of  the  lucid  intervals.  They  may  be  complicated 
by  other  forms  of  psychoses,  but  in  the  main  it  is  possible 
to  pick  out  certain  points  in  the  symptomatology  and  clinical 
course  of  the  disease  which  suggest  a  common  basis.  It  is 
advisable  for  the  present,  in  the  consideration  of  dementia 
prsecox  as  well  as  in  the  description  of  the  manic-depressive 
psychoses,  to  refrain  from  designating  these  two  groups  as 
definite  disease  entities.  The  present  differentiation  of  these 
cases  is  in  a  measure  temporary,  but  the  principles  on  which 
it  is  made  are  consistent  with  and  not  antagonistic  to  progress. 

Before  attempting  to  study  the  clinical  course  of  the  cases 
which  are  brought  together  under  the  head  of  manic-depressive 
insanity,  it  is  essential  that  there  should  be  as  clear  and  defi- 
nite a  conception  as  possible  of  the  individual  symptoms  and  of 
the  relation  they  bear  to  each  other  in  the  clinical  course  of  the 
disease. 

I.  Maniacal  Phase.  Motor  Symptoms. — In  this  period 
the  majority  of  patients  exhibit  motor  symptoms  which  are 


MANIC-DEPRESSIVE    INSANITY  33c, 

definite  and  in  a  measure  specific.  The  one  most  apparent  to 
the  casual  observer  is  the  general  restlessness.  The  majority 
of  maniacal  patients  are  never  still.  In  the  incipient  stages 
every  thought  and  new  idea  is  immediately  translated  into 
action;  there  is  a  psychomotor  excitability;  movement  is 
easy ;  rest  is  impossible.  The  initial  symptoms  are  often  char- 
acterized by  a  tendency  to  have  many  irons  in  the  fire,  to 
engage  in  new  undertakings,  to  become  unusually  strenuous, 
to  be  always  bustling  or  seeking  for  some  new  outlet  for  the 
discharge  of  excessive  energy.  Frequently  an  individual,  who 
has  been  seclusive  or  quiet  in  demeanor,  becomes  vivacious, 
never  has  a  moment  to  spare,  is  obtrusively  animated,  plunges 
into  society,  is  meddlesome,  insists  on  beginning  new  under- 
takings without  waiting  to  count  the  cost.  Every  psychic 
impulse,  however  vague  and  indefinite,  seems  to  suggest  new 
fields  of  activity.  The  excitability  is  ideational  as  well  as 
motor  in  character.  In  some  instances  the  former  in  others 
the  latter  type  predominates.  Occasionally  cases  are  observed 
in  which  the  motor  irritability,  although  excessive,  does  not 
seem  to  affect  the  speech  centres.  In  other  instances  the  con- 
verse is  true,  and  in  the  absence  of  other  motor  symptoms  the 
patient  keeps  up  a  steady,  uninterrupted  chatter.  This  motor 
excitability  varies  greatly  in  different  cases.  Sometimes,  in 
the  early  stages,  it  may  be  hardly  perceptible,  and  gradually 
increases  only  after  a  considerable  lapse  of  time  to  its  maxi- 
mum intensity,  whereas  in  other  instances  it  reaches  its  full 
development  within  a  few  hours.  It  may  become  so  intense 
and  diffuse  as  to  implicate  all  the  muscles  of  the  body  and  in- 
capacitate the  individual  for  the  performance  of  coordinated 
muscular  movements,  so  that  he  is  unable  to  leave  his  bed. 
Accompanying  the  incoordinated  and  involuntary  movements 
there  are  marked  tremulousness  and  an  unsteadiness  which 
occasionally  becomes  choreiform  in  type,  although,  as  a  rule, 
the  movements  are  less  jerky  and  impulsive.  The  tremor  in 
the  milder  cases  is  only  perceptible  in  the  extremities  and 
tongue  and  may  scarcely  be  noticeable  in  the  facial  muscles. 
As  the  intensity  of  the  motor  symptoms  increases  the  tremor 


34Q 


PSYCHIATRY 


becomes  more  and  more  marked  until  the  excursions  may  be- 
come so  exaggerated  as  to  give  rise  to  considerable  uncertainty 
in  all  volitional  acts.  During  a  maniacal  attack  the  actual 
muscular  strength  of  patients  sometimes  seems  to  be  increased, 
but  this  phenomenon  is  referable  to  the  insensitiveness  to  pain 
and  the  absolute  indifference  to  injury  which  characterizes 
the  conduct  of  so  many  individuals  during  this  stage.  The 
exaggeration  of  the  functional  power  of  the  muscles  is  apparent 
rather  than  real  and  depends  upon  the  absence  of  inhibition 
no  less  than  upon  the  recklessness  of  the  individual.  During 
the  periods  of  wildest  excitement  the  patients  rush  heedlessly 
about  the  wards,  striking  or  attacking  whoever  chances  to 
come  in  their  way,  throwing  themselves  blindly  against  the 
furniture  or  walls,  and  exhibiting  homicidal  as  well  as  sui- 
cidal tendencies.  Associated  with  these  displays  of  brute  force 
there  is  nearly  always  a  diminution  of  the  pain  sense  which  is 
centrally,  not  peripherally,  conditioned.5  The  patients  inflict 
upon  themselves  all  manner  of  injury  without  evincing  the 
slightest  appreciation  of  pain.  One  case  is  on  record  in  which 
a  patient  actually  tore  his  tongue  loose  from  its  attachments 
during  a  period  of  maniacal  excitement.  Even  in  the  rela- 
tively mild  grades  the  speech  of  the  patient  pretty  constantly 
shows  certain  definite  changes.  The  compulsion  to  talk  be- 
comes noticeable.  The  individual  who  has  been  more  or  less 
reticent  and  restrained  is  voluble,  flippant,  and  a  mere  driv- 
eller. Not  only  is  this  change  noticeable,  but  the  emotional 
state  also  fluctuates.  An  individual  who  prior  to  the  attack 
has  been  more  or  less  stupid  becomes  witty,  sharp  at  repartee, 
or  a  mere  buffoon.  The  tendency  to  joke,  to  pun,  to  form 
sound  associations  and  alliterations  are  features  that  become 
more  prominent  as  the  case  develops.  In  the  majority  of  cases 
there  is  the  so-called  flight  of  ideas,  a  symptom  which  has 
been  described  more  in  detail  in  the  introductory  chapters. 
It  is  important  to  note  that  the  steady,  uninterrupted  flow  of 

5  Paton,  Stewart :    The  American  Journal  of  Insanity,  vol.  Iviii,  No.  4, 
1902. 


MANIC-DEPRESSIVE    INSANITY 


341 


words  is  the  result  of  both  intra-  and  extra-organic  stimuli. 
Not  only  do  the  words  used  suggest  to  the  patient  new  ideas, 
to  which  immediate  expression  is  given,  but  the  sound  and 
rhyme  associations  are  also  eminently  characteristic.  Exter- 
nal stimuli  serve  to  deflect  and  give  a  definite  trend  to  what 
the  patient  says.  The  actual  rapidity  in  the  association  of  ideas 
is  not  increased;  the  flight  of  ideas  is  indicative  of  mental 
insufficiency  rather  than  over-productiveness. 

Hoch  has  made  the  suggestion  that  the  use  of  the  term 
"  flight  of  ideas"  to  characterize  all  forms  of  rapid  psychic 
discharges  is  in  some  instances  inappropriate  on  account  of  the 
disconnected  and  irrational  character  of  the  conversation.  In 
each  case  the  complex  should  be  analyzed  as  far  as  possible, 
as  the  causes  as  well  as  the  variations  in  this  combination  of 
symptoms  are  not  well  understood. 

In  some  cases  the  inordinate  desire  to  write  is  no  less 
marked  than  the  speech  compulsion.  The  quantity  of  notes 
and  letters  that  these  persons  indite  is  frequently  astounding. 
The  way  in  which  they  express  themselves  and  the  character 
of  the  association  of  ideas  bear  a  striking  similarity  to  the 
mannerisms  and  idiosyncrasies  of  speech.  Kraepelin  has  made 
a  number  of  interesting  studies  to  determine  the  essential 
characteristics  of  the  writing  of  these  patients.  By  means 
of  a  special  apparatus  (Schriftwage)  the  force  and  the  dura- 
tion of  the  muscular  movements  were  graphically  recorded 
and  measured,  and  it  was  found  that  the  rapidity  with  which 
the  penstrokes  were  made  and  the  amount  of  pressure  expended 
in  their  execution  during  this  stage  were  exaggerated.  Even 
in  mild  cases  the  contrasts  that  exist  in  the  character  of  the 
writing  during  the  periods  of  depression  and  excitement  are 
striking. 

The  facial  expression  during  the  period  of  excitement 
corresponds  with  the  prevailing  emotional  tone,  and  by  rapid 
and  exaggerated  changes  often  reveals  the  affective  instability. 
Occasionally  there  seems  to  be  an  asymmetrical  play  of  the  fa- 
cial muscles.  The  action  of  the  muscles  of  speech  and  degluti- 
tion is  impaired  only  in  the  severer  forms  of  the  disease. 


342  PSYCHIATRY 

Sensations. — Except  in  mild  cases  it  is  extremely  diffi- 
cult to  make  a  careful  examination  of  the  sensations.  As  a 
rule,  however,  no  marked  disturbances  in  the  functions  of  the 
peripheral  nerves  are  found.  As  the  excitement  increases  the 
attention  of  the  patient  lapses  more  and  more,  at  times  being 
riveted  upon  certain  portions  of  his  own  field  of  consciousness. 
If  the  peripheral  sensation  is  tested  at  such  times  the  ob- 
server ma}-  be  led  to  believe  that  touch  or  pain  sensation  is 
greatly  impaired,  inasmuch  as  there  is  no  apparent  response 
to  stimuli,  whereas,  as  a  matter  of  fact,  this  condition  depends 
purely  upon  the  psychical  state  of  the  individual.  The  min- 
ute the  patient's  attention  is  directed  to  that  portion  of  the 
body  in  which  sensation  is  being  tested  it  will  become  appa- 
rent that  the  slightest  touch  or  pin  prick  is  at  once  appre- 
hended. Not  infrequently  in  the  early  stages  the  patients  are 
hyperaesthetic  for  different  forms  of  peripheral  stimulation. 
Vague  hallucinations  of  the  various  sensations  are  not  uncom- 
mon; particularly  the  elementary  forms  such  as  indefinite 
sounds,  lights,  etc.  Well-defined  persistent  hallucinations  do 
not  occur  in  the  majority  of  cases.  Those  that  are  met  with, 
as  a  rule,  vary  greatly  in  form  and  change  with  remarkable 
rapidity.  On  account  of  the  marked  fluctuations  in  the  atten- 
tion and  the  excited  condition  of  the  patient  illusions  are  even 
more  frequent  than  definite  hallucinations.  The  voices  of 
patients  or  attendants  are  mistaken  for  those  of  intimate 
friends.  Sounds  heard  in  the  wards  are  immediately  associated 
with  scenes  directly  connected  with  the  patient's  own  per- 
sonality or  environment  at  home.  Psychic  hallucinations  are 
not  frequently  observed.  Occasionally,  however,  patients  af- 
firm that  they  are  subject  to  visions  which,  as  a  rule,  are  asso- 
ciated with  motion  and  only  temporarily  invade  the  field  of 
consciousness.  The  objectivity  as  well  as  the  time  and  spatial 
relations  of  these  fallacious  sense  perceptions  may  be  very 
indefinite. 

The  associative  functions  of  the  brain  are  generally  more 
or  less  seriously  disorganized.  In  the  milder  cases  this  defect 
does  not  at  once  become  apparent.     The  patient's  power  of 


MANIC-DEPRESSIVE    INSANITY 


343 


orientation  may  be  well  preserved,  the  disturbances  in  con- 
sciousness becoming  marked  only  when  the  symptoms  have 
reached  a  certain  degree  of  intensity  and  the  motor  restlessness 
and  flight  of  ideas  have  become  important  factors.  The  first 
change  in  the  psychic  process  is  the  absence  of  normal  inhibi- 
tion and  the  consequent  tendency  towards  the  overvaluation 
of  the  minor  processes  in  associative  thought.  There  is  a 
temporary  abolition,  as  it  were,  of  the  selective  and  critical 
faculties  due  primarily  to  the  absence  of  inhibition.  Every 
idea  that  flashes  into  the  patient's  mind  instantly  becomes  of 
equal  importance  with  the  one  that  has  immediately  preceded 
it.  It  is  not  improbable  that  in  cases  of  maniacal  excitement 
two  essentially  different  factors,  ( I )  a  loosening  of  the  asso- 
ciative mechanism  and  (2)  a  psycho-sensorial  super-produc- 
tion, are  concerned  in  the  symptomatology.  As  has  frequently 
been  suggested,  the  clinical  picture  is  composite  and  may  be 
considered  to  be  caused  by  incident  stimuli  with  exaggerated 
reactions  as  well  as  by  the  effects  of  certain  paralyzing  agents. 
The  relationship  that  exists  between  these  two  factors  is  best 
expressed  in  the  law  of  psychic  antagonism  enunciated  by 
Friedmann,  who  affirms  that  no  psychic  function  is  increased 
without  impairment  of  others.  The  power  of  directing  the 
attention  is  seriously  impaired.  At  times,  however,  there  may 
be  what  might  be  termed  a  semi-tetanization,  the  patient  con- 
centrating for  an  instant  all  his  faculties  upon  certain  objects. 
It  is  this  phenomenon  which  has  led  some  observers  to  believe 
that  there  is  an  actual  increase  in  the  power  to  focus  the 
attention  (hyperprosexia).  The  impairment  of  the  critical 
faculties  is  marked  in  nearly  all  cases  of  maniacal  excitement. 
The  incident  stimuli  seem  to  spread  in  all  directions  and  the 
result  may  be  a  temporary  but  complete  transformation  in 
an  individual,  so  that  he  becomes  unusually  vivacious,  humor- 
ous, sprightly,  witty,  and  displays  what  to  the  casual  observer 
appears  to  be  an  intellectual  super-productiveness.  During  the 
stages  of  greatest  excitement  the  patients  become  oblivious 
to  the  environment  in  which  they  belong  and  become  utterly 
unconscious  of  their  own  physical  as  well  as  their  intellectual 


344  PSYCHIATRY 

limitations.  They  affirm  that  they  are  as  strong  as  Hercules, 
as  rich  as  Croesus;  the  poorly  dressed  and  poverty-stricken 
woman  becomes  a  queen,  etc.  These  insane  ideas  vary  often 
from  those  characterized  by  a  moderate  degree  of  complacency 
and  exaltation  to  the  wildest  exaggerations  and  extravagances. 
Inconstancy  and  capriciousness  are  eminently  characteristic  of 
the  mental  state  of  the  maniacal  patient.  The  systematization 
of  the  insane  ideas,  if  it  exists  at  all,  is  apt  to  be  merely  tran- 
sitory. 

The  power  to  pick  up  and  retain  new  impressions  is  di- 
minished in  proportion  to  the  increase  in  the  amount  of  energy 
expended  in  the  focussing  of  the  attention.  In  the  earlier 
stages  or  in  the  milder  cases  the  patients  not  infrequently  re- 
tain only  those  impressions  of  their  surroundings  or  of  cur- 
rent events  that  can  be  taken  in  at  a  glance.  The  more  com- 
plicated memories  are  seriously  impaired. 

Anomalies  of  the  Emotions. — The  anomalies  of  emotion 
are  frequent  and  varied  in  character.  In  nearly  all  cases  dur- 
ing the  earlier  stages  a  marked  feeling  of  exaltation  is  present. 
The  patients  are  pleased,  self-complacent,  and  in  the  best  of 
humors.  Unquestionably,  changes  in  the  organic  sensations, 
such  as  absence  of  the  ordinary  sense  of  fatigue,  may  in  a 
measure  be  responsible  for  this  mental  attitude.  As  the  mani- 
acal stage  advances  this  exaltation  increases  rapidly.  The  indi- 
vidual becomes  vivacious,  elated,  hilarious,  is  thrown  into 
transports  of  delight  or  ecstasy ;  later  he  is  boastful,  gives  vent 
to  the  wildest  statements,  and  becomes  a  mere  blusterer.  The 
correlative  emotional  expressions  are  all  exaggerated.  The 
patient  laughs  loudly  and  long  on  the  slightest  provocation, 
throwing  his  head  back,  opening  his  mouth  wide,  and  giving 
vent  to  his  feelings  in  a  preposterous  manner.  In  some  cases, 
instead  of  the  feeling  of  exaltation,  excessive  irritation  is  noted 
and  the  individual  becomes  domineering  and  subject  to  violent 
outbursts  of  temper.  The  slightest  interference  with  what  is 
his  will  may  result  in  an  emotional  storm  of  great  intensity, 
which,  however,  often  ends  as  abruptly  as  it  has  begun.  On 
the  other  hand,  some  patients  become  most  affectionate.     They 


MANIC-DEPRESSIVE    INSANITY 


345 


claim  every  one  as  their  intimate  friend.  Accompanying  these 
emotional  changes,  not  infrequently  there  is  marked  sexual 
excitement.  This  may  be  limited  to  a  mere  expression  of  satis- 
faction at  being  in  the  presence  of  the  opposite  sex,  or  erotic 
impulses  may  lead  to  sexual  perversion — masturbation,  exces- 
sive intercourse,  attempts  at  rape,  etc.  During  this  period  men 
as  well  as  women  may  become  vulgar,  obscene,  lose  all  sense  of 
decency,  and  exhibit  an  inordinate  fondness  to  converse  on 
topics  relating  to  the  question  of  the  sexes  and  marriage.  The 
development  of  these  symptoms  in  many  instances,  if  the  pa- 
tients are  not  under  restraint,  gives  rise  to  complications  of 
medico-legal  importance. 


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■  Pulse        R,  reclining        S,  sitting  up  in  bed 


Case  of  Manic-Depressive  Insanity.  Depression  with  anxiety.  To  illustrate  diSerences 
in  rapidity  of  pulse  and  in  blood-pressure  in  the  sitting  and  reclining  postures  respectively. 
Variations  are  greater  than  normal. 

The  physical  symptoms  of  mania  are  those  common  to 
most  of  the  forms  of  mental  excitement  accompanied  with 
motor  restlessness.  The  pulse,  as  a  rule,  is  accelerated,  the 
rapidity  rising  as  the  motor  restlessness  increases.     The  blood- 


346  PSYCHIATRY 

pressure  in  most  of  the  uncomplicated  cases  is  low  during  the 
period  of  excitement.  Slight  causes — a  person  entering  the 
room,  a  sudden  noise,  or  anything  which  attracts  the  attention 
— frequently  produces  wide  variations  in  pulse  and  in  blood- 
pressure.  The  accompanying  chart  graphically  shows  how  in 
one  of  our  cases  a  change  of  posture  produced  a  wide  variation 
when  the  patient  was  in  an  agitated  condition  and  a  less  wide 
variation  when  the  patient  was  somewhat  stuporous. 

Other  observations  tend  to  confirm  those  of  Dawson,6 
who  affirms  that  "  the  characteristic  feature  of  the  general 
circulation  in  excitement  and  probably  in  exaltation  is  low 
arterial  tension  which  helps  to  maintain,  if  it  does  not  cause, 
the  mental  state."  But  "  here  again  there  is  no  direct  evidence 
of  the  state  of  the  cerebral  circulation." 

Pilcz  has  called  attention  to  the  marked  correspondence 
which  exists  between  the  pressure,  frequency,  and  sphygmo- 
graphic  tracings  of  the  pulse  in  cases  during  the  stage  of  ex- 
citement as  contrasted  with  the  results  of  similar  observations 
made  during  the  period  of  depression.  From  this  it  must  not 
be  inferred  that  there  are  pulse-curves  characteristic  of  the 
manic  and  of  the  melancholic  periods.  The  personal  variation, 
however,  must  be  considered  in  each  individual  case.  The 
examination  of  the  blood  during  the  maniacal  stage  reveals 
no  characteristic  changes.  Fisher,7  after  a  careful  examination 
of  the  blood  in  a  number  of  cases,  has  come  to  the  following 
conclusions  :  ( i )  there  is  no  pathognomonic  blood  change  dur- 
ing the  maniacal  phase;  (2)  anaemia  is  not  a  causative  nor  a 
constant  factor;  (3)  the  haemoglobin  and  red  cells  are  fre- 
quently increased  in  number  during  the  attack,  and  (4)  leuco- 
cytosis  is  almost  a  constant  accompaniment  and  apparently  a 
result  of  psychomotor  activity.  The  reported  variations  in  its 
alkalinity  have  not  been  confirmed.8    The  breathing  during  the 


6  The  Role  of  the  Blood  Supply  in  Mental  Pleasure  and  Pain.  Dublin 
Journal  of  Medical  Science,  February,  1900. 

T  Fisher,  Jessie  Weston :  The  Blood  in  Manic-depressive  Insanity. 
Am.  Journ.  Insan.,  1903,  vol.  lix,  No.  4. 

8  Lambranzi :    Rivista  di  patologia  nervos.  e  mentale,  1899,  fasc.  vii. 


PLATE  VII 


September,  1904 


Chart  showing  temperature,  pulse,  and  respiration  curves  in  a  case  of  manic-depressive 
insanity.  On  admission  the  patient  was  excited,  but  soon  became  more  quiet  (A).  After 
two  weeks  the  excitement  returned  (ft)  and  became  more  marked  than  it  had  been  at  the 
time  of  admission. 


MANIC-DEPRESSIVE    INSANITY 


347 


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(I.)  Case  of  manic-depressive  insanity  showing  loss  and  gain  of  weight,  increase  in  aver- 
age hours  of  sleep,  and  indicating  schematically  changes  in  emotional  and  motor  spheres.  In- 
tellectually, prior  to  attack,  patient  was  slightly  deficient.  Dotted  lines  indicate  condition 
before  admission  to  hospital. 


348 


PSYCHIATRY 


periods  of  greatest  excitement  is,  as  a  rule,  somewhat  shallower 
and  increased  in  rapidity  as  compared  with  the  normal.  Some 
observers  have  reported  a  rise  in  the  temperature  varying  from 
0.50  to  20  C.     The  bodily  weight  nearly  always  falls  during 


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(II.)  Case  of  manic-depressive  insanity  of  short  duration.  Chart  shows  loss  and  gain  of 
weight,  increase  in  average  hours  of  sleep,  and  indicates  schematically  the  changes  in  intel- 
lectual, emotional,  and  motor  spheres. 

the  period  of  excitement.  (Charts.)  Sometimes  there  is  a 
rapid  drop  of  several  pounds.  At  other  times  the  loss  is  more 
gradual  and  is  in  a  measure  proportional  to  the  motor  excite- 
ment. 

The  changes  in  the  chemical  constituents  of  the  urine  are 
not  characteristic.     During  the  height  of  the  attack  peptone 


MANIC-DEPRESSIVE    INSANITY 


349 


and  albumin  are  not  infrequently  present,  but  these  disappear, 
as  a  rule,  as  the  excitement  diminishes. 

Symptoms  indicating  the  existence  of  destructive  lesions 
in  the  central  nervous  system  are  not  infrequently  reported. 
The  instances  in  which  hemiplegias  occur  are  due  to  compli- 
cating focal  lesions.  The  same  is  true  of  the  facial  paralyses 
as  well  as  those  implicating  the  ocular  muscles.  Occasionally 
convulsions  take  place  during  the  period  of  excitement.  When 
these  are  noted  they  are  extremely  suggestive  of  the  existence 
of  epilepsy.  The  various  symptoms  arising  from  over-stimu- 
lation or  paralysis  of  the  sympathetic  are  not  infrequent  dur- 
ing the  attacks.  In  some  instances  it  has  been  possible  to  con- 
firm the  observations  of  Schott,  Ball,  Regis,  von  Wagner,  Men- 
del, and  others  regarding  the  occurrence  during  the  period  of 
excitement  of  pupillary  differences.  As  a  rule,  the  pupils  are 
widely  dilated  and  react  to  light.  The  superficial  and  deep 
reflexes  are  generally  increased.  The  occurrence  of  ankle- 
clonus  during  the  period  of  greatest  excitement  has  occasion- 
ally been  noted. 

Disturbances  in  the  gastro-intestinal  tract,  giving  rise  to 
anorexia,  nausea,  vomiting,  and  constipation,  are  nearly  always 
present.  The  disorders  are  not  improbably  due  in  a  majority 
of  the  cases  to  functional  disturbances  involving  the  internal 
secretions.  In  many  cases  there  is  a  marked  salivation  and 
diminished  sweat  secretion.  In  some  cases,  if  given  an  op- 
portunity, patients  bolt  large  quantities  of  food, — bulimia, — ■ 
but  frequently,  on  account  of  the  motor  restlessness,  it  is  ex- 
tremely difficult  to  feed  them. 

II.  The  State  of  Depression. — By  some  this  condition 
has  been  regarded  as  the  antithesis  of  the  period  of  maniacal 
excitement.  This  is  true,  however,  only  in  a  very  limited  sense. 
In  nearly  all  cases  of  depression  certain  symptoms  occur  which 
are  also  to  be  met  with  during  the  cycle  of  greatest  mental  per- 
turbation. Not  only  is  this  a  fact,  but  the  gradations  which 
exist  between  marked  manic  excitement,  on  the  one  hand,  and 
deep  depression,  upon  the  other,  are  so  gradual  that  it  is  sel- 
dom justifiable  to  consider  the  two  states  as  fundamentally 


350  PSYCHIATRY 

antithetical.  As  motor  restlessness  is  a  prominent  symptom 
of  mania,  so  the  psychomotor  retardation  may  be  equally  char- 
acteristic of  the  state  of  depression. 

The  motor  anomalies  occurring  during  the  period  of  de- 
pression are  referred  to  by  Wernicke  as  the  expression  of  an 
intra-psychic  akinesis.  The  appearance  of  the  patient  suggests 
a  general  diminution  in  the  ideomotor  activities  of  the  cere- 
bral cortex.  All  movements  are  slow  and  made  with  difficulty. 
As  has  been  pointed  out,  the  reactive  are  less  interfered  with 
than  the  so-called  initiative  movements.  This  is  particularly 
true  for  speech.  The  reply  to  a  simple  question  is  given  only 
after  the  lapse  of  a  considerable  interval  of  time,  the  tone  and 
pitch  of  the  voice  are  lowered,  the  intensity  of  all  movements 
of  the  lips  and  tongue  is  greatly  diminished.  The  same  limi- 
tations are  noticeable  in  many  cases  in  the  facial  innervation. 
The  intensity  of  all  voluntary  movements,  not  only  of  the  face, 
but  of  the  extremities  and  trunk,  is  generally  impaired.  Asso- 
ciated with  the  delay  in  the  muscular  reaction  and  decrease 
of  the  intensity  of  movements  in  many  cases  there  is  an  accom- 
panying emotional  depression  as  well  as  a  retardation  in  the 
processes  concerned  in  thought.  These  symptoms  vary  greatly. 
In  the  mild  cases  psychomotor  retardation  and  the  psychical 
feeling  of  depression  are  sometimes  made  out  only  with  diffi- 
culty. The  antecedent  motor  restlessness  and  slight  exaltation 
may  serve  to  bring  these  symptoms  into  sharp  contrast  and 
thus  facilitate  their  recognition  as  abnormalities,  and  not  the 
mere  expression  of  a  personal  idiosyncrasy. 

In  other  cases  the  retardation  of  thought  and  action  is 
well  marked,  and  associated  with  this  there  is  considerable  emo- 
tional depression.  The  emotional  instability  so  characteristic 
of  the  maniacal  state,  as  a  rule,  disappears  during  the  period 
of  depression,  and  is  replaced  by  an  unbroken  and  stable  af- 
fective tone.  On  account  of  the  retardation  that  exists,  the 
examiner  may  be  led  to  believe  that  the  primary  sensations 
are  not  intact,  but  the  difficulty  of  testing  patients  in  this  con- 
dition is  so  great  that,  as  a  rule,  definite  conclusions  cannot 
be  drawn.     The  reaction  time  during  the  period  of  depression 


MANIC-DEPRESSIVE    INSANITY  351 

is  greatly  lengthened.  The  pulse  generally  becomes  slower. 
The  blood-pressure,  which  was  low  during  the  period  of  manic 
excitement,  other  things  being  equal,  rises  during  the  de- 
pression. The  changes  in  the  handwriting,  as  would  be 
expected  from  the  retardation  of  all  voluntary  movements,  are 
characteristic.  Reference  has  already  been  made  to  this  point 
in  discussing  the  symptoms  of  the  manic  excitement.  In  some 
cases  the  retardation  of  thought  and  action  is  less  marked 
than  the  emotional  depression.  This  will  be  discussed  in  con- 
sidering the  mixed  forms.  In  the  milder  cases  time  and  spa- 
tial orientation  are  well  preserved,  but  in  the  severer  types 
there  may  be  marked  confusion.  Sometimes  the  patients  are 
conscious  of  the  subjective  difficulty  in  the  associative  proc- 
esses. They  not  infrequently  affirm  that  they  are  unable  to 
speak  or  to  think;  they  appreciate  the  difficulties,  but  are 
unable  to  assign  any  definite  reason  for  them.  The  somato- 
psychic consciousness  is  markedly  affected.  As  a  rule,  it  may 
be  said  that  the  patients  are  simply  depressed  mentally,  while 
in  some  cases  there  is  superadded  a  feeling  of  vague  appre- 
hension, which  later  develops  into  marked  anxiety.  The  emo- 
tional depression  deepens  as  the  patients  become  more  or  less 
conscious  of  their  inability  to  think  or  act.  Everything  is 
difficult  for  them.  This  emotional  state  may  be  intensified  by 
the  appearance  in  consciousness  of  anomalous  sensations,  anx- 
iety, fear  of  impending  death,  and  various  painful  states  which 
in  cases  of  extreme  rarity  are  peripherally  conditioned,  but,  as 
a  rule,  are  merely  symptoms  of  psychic  pain.  Imperative  con- 
ceptions sometimes  dominate  the  field  of  consciousness,  and 
these  may  give  rise  to  more  complicated  phenomena,  especially 
if  they  persist  for  any  length  of  time.  In  some  instances  the 
cropping  up  of  imperative  ideas  may  be  the  basis  for  a  sys- 
tematized micromania.  In  the  milder  cases  this  may  be  absent 
and  merely  a  feeling  of  insufficiency  exists.  The  patients  affirm 
that  they  once  were  able  to  do  their  work,  but  the  increased 
difficulty  in  thinking  and  in  the  execution  of  voluntary  acts 
incapacitates  them.  In  the  extreme  cases  a  marked  akinesis 
may  result. 


352 


PSYCHIATRY 


Not  infrequently  insane  ideas  develop.  In  some  instances, 
particularly  in  the  uncomplicated  forms,  they  represent  an 
attempt  on  the  part  of  the  patient  to  interpret  the  change  in 
the  organic  sensations.  Such  a  condition  may  seriously  dis- 
turb the  individual's  ideas  of  his  own  personality  or  may  alter 
his  apparent  relationships  to  his  environment.  On  the  former 
basis  we  have  the  development  of  the  ideas  of  self -insufficiency 
and  personal  unworthiness  or  the  commission  of  unpardonable 
sins  for  which  there  is  an  immediate  and  awful  retribution. 
Thus  a  patient  will  frequently  assume  that  he  is  the  most 
wicked  person  God  ever  created,  and  the  like.  Various  hypo- 
chondriacal symptoms  may  also  be  superadded.  In  the  latter 
instances  the  dissociation  in  the  consciousness  of  the  external 
world  culminates  in  ideas  of  persecution,  etc.  The  develop- 
ment of  insane  ideas  out  of  obsessional  impulses  and  hallu- 
cinations is  considered  by  some  clinicians  as  indicating  the 
occurrence  of  complications.  Heller  9  has  affirmed  that  hallu- 
cinations are  comparatively  infrequent  during  the  course  of 
melancholia.  According  to  Ziehen  in  depression  they  only 
occur  in  one  out  of  ten  cases.  Schott,10  who  examined  250 
patients  suffering  from  melancholia  with  this  special  point  in 
view,  reported  the  occurrence  of  hallucinations  in  only  28.8  per 
cent.,  hypochondriacal  ideas  in  27.6,  and  imperative  concep- 
tions in  8  per  cent,  of  the  cases. 

The  inhibition  of  the  psychical  faculties  may  become  so 
marked  that  the  patients  pass  into  a  stuporous  condition.  To 
all  outward  appearances  they  seem  to  lead  a  merely  vegetative 
existence.  External  stimuli  fail  to  produce  any  evident  reac- 
tion; or,  at  most,  a  simple  reflex  movement  follows.  There 
is  no  elaboration  or  working  up  of  incident  stimuli.  The 
patients,  as  a  rule,  remain  in  bed.  They  do  not  refuse  to 
take  food,  but  they  have  to  be  fed.  Occasionally  a  slight 
swallowing  movement  is  made;    at  other  times  the  fluid  runs 


9  Heller,  E. :    Die  Wahnideen  der  Melancholiker.     Inaug.  Diss.     Mar- 
burg, 1898. 

10  Beitrag  zur  Lehre  von  der  Melancholie. 


MANIC-DEPRESSIVE    INSANITY  353 

from  the  mouth.  After  the  patient  has  recovered,  generally 
the  memory  for  that  period  during  which  the  psychic  inhibi- 
tion and  retardation  were  at  their  maximum  is  a  mere  blank ; 
at  other  times  there  are  islands  in  memory — some  events  being 
plainly  recollected,  while  others  are  completely  forgotten. 

The  physical  symptoms  in  this  stage,  with  the  exception 
of  those  already  noted,  do  not  differ  essentially  nor  specifically 
from  those  recorded  during  the  period  of  the  motor  excite- 
ment. 

Clinical  Course. — The  course  of  the  disease  is  character- 
ized by  the  appearance  of  symptoms  that  give  to  the  clinical 
picture  now  the  signs  of  maniacal  exaltation  or  again  that  of 
mental  depression  with  their  correlative  physical  attributes. 
The  syndrome  of  exaltation  and  motor  restlessness  may  alter- 
nate with  that  of  depression  and  psychomotor  retardation.  In 
other  cases  the  dominant  emotional  tone  and  concomitant  physi- 
cal state  ushering  in  the  symptoms  may  persist  with  slight 
modification  until  the  end  of  the  attack,  a  temporary  sugges- 
tion of  the  so-called  antithetical  state  only  occasionally  coming 
into  view.  Not  infrequently  there  is  an  intermixture  of  symp- 
toms so  that  the  emotional  tone  characteristic  of  one  state  is 
attended  by  the  physical  signs  generally  associated  with  the 
other  condition.  The  tendency  of  the  attacks  to  recur  at  longer 
or  shorter  intervals  is  another  distinctive  feature  of  the  dis- 
ease. The  lucid  intervals,  which  are  essentially  characteristic, 
are  not  marked  by  the  development  of  other  forms  of  mental 
aberration,  such  as  paranoiic  states  or  dementing  processes. 

This  group  includes  simple  and  recurrent  manias  and  mel- 
ancholias as  well  as  the  various  forms  of  circular  insanity  and 
the  so-called  recurrent  paranoias  that  do  not  exhibit  symptoms 
of  a  specific  mental  reduction  in  the  lucid  intervals.  The  dis- 
cussion of  the  features  characteristic  of  the  different  clinical 
groups  will  be  taken  up  under  the  following  heads : 

(1)  States  in  which  the  dominant  symptoms  are  exhila- 
ration and  motor  restlessness.  This  form  may  rightly  be  said 
to  include  all  cases  of  the  typical  or  classical  type  of  mania  as 
well  as  the  milder  forms,  such  as  hypomania,  mania  without 

23 


354  PSYCHIATRY 

delirium,  some  of  the  delirious  manias,  as  well  as  some  forms 
in  which  the  motor  restlessness  and  exaltation  show  a  tendency 
to  run  a  protracted  course  and  the  insane  ideas  become  more 
or  less  systematized.  The  cases  which  were  formerly  de- 
scribed as  instances  of  pure  mania  are  very  infrequent.11  They 
include  only  from  one  to  three  per  cent,  of  all  the  cases.  As 
a  rule,  this  type  is  met  with  more  often  in  the  earlier  than  in 
the  later  years  of  life,  although  some  clinicians  affirm  that  it 
not  infrequently  appears  in  young  children  in  the  atypical  form. 
Many,  if  not  all,  of  the  so-called  cases  of  simple  mania,  if 
studied  with  sufficient  care,  show  at  some  time  during  their 
course  the  symptoms  which  are  commonly  associated  with  the 
period  of  depression, — viz.,  the  psychomotor  retardation,  the 
limitation  and  delay  in  the  functions  of  association,  mental 
depression,  etc. 

These  symptoms  may  be  only  transitory  in  character 
and  easily  escape  the  notice  of  the  physician.  As  a  rule, 
the  disease  begins  with  an  initial  stage  of  longer  or  shorter 
duration  in  which  the  patient  becomes  nervous,  irritable,  un- 
duly responsive  to  all  forms  of  stimuli.  There  may  be  marked 
sleeplessness  of  which  the  patient  does  not,  as  a  rule,  com- 
plain. The  motor  excitement  may  be  general  or  in  some  in- 
stances limited  to  the  speech  centres.  If  stimulated,  the  pa- 
tient becomes  voluble,  and  the  function  of  the  inhibitory 
centres  is  apparently  temporarily  abolished.  It  is  not  infre- 
quently the  case  that  this  so-called  prodromal  period  repre- 
sents a  depressed  stage.  If  such  a  state  exists,  the  patient 
speaks  little,  becomes  seclusive;  or,  if  he  does  speak,  he  may 
be  thought  to  be  hypochondriacal  on  account  of  the  numerous 
complaints  expressed  concerning  his  bodily  state.  Gastro- 
intestinal disturbances  are  not  infrequent.  Headaches  occur, 
and  in  place  of  actual  depression  there  may  be  merely  an  in- 
definite feeling  of  insufficiency  or  marked  anxiety.  This 
initial   stage,   which  in   some  instances   is  a  true  prodromal 


u  Hinrichsen :     Allg.    Ztschr.    f.    Psych.,    Bd.    liv.      Mayser :     NeuroL 
Centralbl.,  1898,  Nr.  11. 


MANIC-DEPRESSIVE    INSANITY  355 

period,  merely  ushering  in  the  maniacal  outbreak,  in  other 
instances  is  more  prolonged,  marking  a  true  period  of  depres- 
sion and  varying  in  duration  from  a  few  days  to  several  weeks. 
The  second  stage  is  one  in  which  the  maniacal  symptoms  of 
motor  restlessness,  exaltation,  emotional  anxiety,  etc.,  attain 
their  maximum  intensity.  In  these  cases  the  diagnosis  is  not 
difficult,  the  patients  presenting  most,  if  not  all,  of  the  symp- 
toms which  have  already  been  described  under  the  head  of  the 
maniacal  phase.  In  the  mania  gravis,  the  motor  agitation  is 
excessive.  The  emotional  storms  that  come  and  go  are  intense 
in  their  severity.  Marked  exaltation  may  alternate  with  or 
be  replaced  by  periods  of  intense  anger.  The  flight  of  ideas 
may  become  masked  by  a  complete  incoherence  and  disasso- 
ciation.  In  the  type  of  cases  described  by  Weygandt 12  as 
unproductive  mania  there  is  marked  motor  restlessness,  with 
considerable  impairment  in  the  associative  processes,  and  a 
marked  deficiency  of  expression  amounting  at  times  to  mutism. 
In  some  of  the  severer  forms  of  the  disease  disorientation  and 
general  mental  confusion  may  persist  for  days  or  even  weeks. 
Death  may  occur  during  this  period,  if  the  patient  is  not  care- 
fully guarded  from  self-inflicted  injury,  or  the  disease  is  com- 
plicated by  pneumonia,  nephritis,  etc.  The  terminal  stage,, 
as  a  rule,  marks  a  gradual  transition  from  the  second  period 
of  the  disease.  The  symptoms,  one  by  one,  become  less  and 
less  marked,  and  the  patient  finally  enters  the  stage  of  con- 
valescence. The  symptoms  of  mania  not  infrequently  persist 
for  several  months  or  even  a  year.  Death  occurs  in  about 
5  per  cent,  of  the  cases.  The  symptoms  characteristic  of 
depression  may  not  become  apparent  until  the  stage  of  con- 
valescence is  reached.  The  mild  cases — mania  mitissima  or 
hypomania — only  occasionally  come  under  treatment  in  hos- 
pitals, and  frequently  present  considerable  difficulty  in  the 
establishment  of  a  diagnosis.  The  following  history  is  typical 
of  these  milder  forms  of  the  disease : 


12  Ueber  die  Mischzustande  des  manisch-depress.  Irreseins.     Miinchenr 
1899. 


356  PSYCHIATRY 

Male ;  single ;  aged  23.  Described  as  young  man  of  high  moral  char- 
acter; of  regular  habits,  studious  and  industrious.  Never  had  any  serious 
illness.  About  two  months  before  admission  to  the  hospital  there  was 
a  change  noticed  in  the  patient's  disposition.  There  was  slight  exalta- 
tion and  excitement ;  "  he  became  unduly  elated  at  his  business  pros- 
pects." Some  garrulity  was  noted.  The  language  was  characterized  by 
slight  extravagances  in  expression.  Later  he  became  slightly  suspicious 
of  some  ot  his  friends,  whom  he  accused  of  having  maligned  his  character. 
Shortly  after  this  he  acquired  a  passionate  desire  for  dancing ;  showed 
no  signs  of  violence,  and  was  apparently  rational,  although  he  always 
seemed  excited  and  acted  as  if  he  were  in  a  hurry.  One  day  prior  to 
admission  to  the  hospital  he  became  confused  and  wandered  aimlessly 
about  for  several  hours.  Was  reckless  in  the  expenditure  of -his  money. 
Went  into  a  strange  store  and  told  the  clerks  that  he  was  prepared  to 
take  charge  of  the  business.  Had  to  be  forcibly  ejected.  During  the 
month  that  the  patient  was  under  observation  in  the  hospital  he  improved 
rapidly.  The  motor  restlessness  became  less  marked,  the  confusion  in 
speech  and  garrulity  disappeared.  His  weight,  which  at  first  had  dropped, 
increased,  and  the  patient  was  finally  discharged  recovered. 

During  the  period  that  the  patient  was  in  the  hospital  a  diagnosis 
of  manic-depressive  insanity  was  made.  Motor  restlessness,  flight  of  ideas, 
and  exaltation  were  the  dominant  symptoms.  Since  the  patient's  discharge 
he  has  had  two  mild  attacks  of  mental  depression. 

When  the  symptoms  of  depression  occur  in  the  terminal 
stage  they  are  not  infrequently  looked  upon  as  mere  reactive 
phases  of  the  acute  stage.  Many  cases  of  the  aggravated  forms 
of  neurasthenia  in  which  there  is  a  well-marked  periodicity 
present  are  unquestionably  to  be  classed  among  these  mild 
cases  of  manic-depressive  insanity.13  During  the  period  of  ex- 
citement the  patients  become  fidgety,  eccentric,  somewhat  ex- 
hilarated, always  in  a  flurry,  slightly  officious,  meddlesome, 
showing  a  desire  to  talk  on  the  slightest  provocation.  Asso- 
ciated with  these  mental  disturbances,  the  bodily  weight  drops 
slightly  and  the  rapidity  of  the  pulse  may  be  somewhat  in- 
creased.    The  emotional  instability  is  often  pronounced. 

In  cases  typified  by  the  history  given,  the  garrulity  of  the 
patients  is  frequently  the  dominant  feature.     The  value  of  this 


13  Hecker  :  Die  Cyclothymia  eine  circulare  Gemiitserkrankung.  Ztschr. 
f.  Praktische  Aerzte,  1897,  Nr.  1,  p.  6.  Die  milder  verlaufenden  Arten  d. 
circularen  Irreseins.  22  Wanderversammlung  der  siidwestdeutschen  Irren- 
arzte  zu  Baden,  2  Sitzung  22,  23  Mai,  1897. 


MANIC-DEPRESSIVE    INSANITY  357 

symptom  necessarily  depends  upon  the  knowledge  the  observer 
has  of  the  character  of  the  patient  prior  to  the  attack.  There 
may  be  no  gross  dissociation  of  thought,  so  that  the  patients, 
on  casual  observation,  may  not  be  considered  incapacitated 
for  work.  The  diagnosis  of  mild  manic  excitement  in  a  great 
measure  depends  upon  the  motor  restlessness.  The  flight  of 
ideas  is  not  necessarily  characterized  by  incoherence,  even  if  a 
tendency  is  shown  to  translate  ideas  into  some  form  of  action. 
While  the  excitement  persists,  the  interests  of  the  patients  seem 
to  enlarge.  Little  escapes  their  attention.  They  plan  new 
enterprises,  enter  with  zest  into  new  undertakings.  The  judg- 
ment, as  a  rule,  is  not  markedly  impaired.  The  conduct  of 
the  patient,  in  a  measure  the  result  of  impulses  which  quickly 
come  and  go,  is  accompanied  by  considerable  emotional  in- 
stability. There  are  not,  however,  the  same  irrelevancy  and  dis- 
connectedness which  characterize  the  conduct  of  patients  af- 
flicted with  dementia  praecox.  The  emotional  instability  of 
the  patient  suffering  from  manic-depressive  insanity,  as  a  rule, 
is  in  response  to  external  stimuli  and  may  have  the  appearance 
of  being  purposeful.  The  emotional  changes  are  rapid,  fluc- 
tuating, and  the  varying  tones  or  shades  of  feeling  are 
strangely  antithetical.  Not  infrequently  the  patients  them- 
selves notice  this  anomalous  state;  thoughts  are  said  to  gal- 
lop through  their  heads  with  unusual  rapidity ;  the}-  complain 
that  they  have  no  rest,  that  they  cannot  free  their  minds 
from  the  various  schemes  which  continually  present  them- 
selves. Not  infrequently  digestive  disturbances  occur  during 
these  attacks  of  mild  maniacal  excitement,  and  in  some  cases 
there  is  a  marked  increase  in  the  rapidity  of  the  pulse.  The 
patients  often  come  under  observation  when  it  is  impossible 
to  determine  the  existence  of  maniacal  symptoms  without  a 
most  careful  study  not  only  of  one  but  of  several  attacks. 
These  cases  were  referred  to  formerly  by  the  French  observers 
as  instances  of  folie  raisoiinante.  After  carefully  studying 
the  symptoms,  it  may  be  possible  to  determine  that  the  increased 
intellectual  activity  of  the  patient  is  apparent  rather  than  real. 
This  is  shown  in  the  rapidity  with  which  patients  pass  from  one 


358  PSYCHIATRY 

subject  to  another;  the  fact  being  that  they  are  the  most  im- 
pressed by  the  ideas  that  at  a  given  moment  occupy  the  focus 
of  their  attention,  never  suspending  judgment  until  they  are 
able  to  form  an  accurate  comparative  estimate  and  thus  to  de- 
termine the  best  course  of  action.  Frequently  the  conversation, 
if  carefully  noted,  brings  to  light  peculiarities  which  are,  in 
a  measure,  distinctive,  such  as  preponderance  of  alliterations, 
etc.  The  absence  of  tact  and  the  dulling  of  the  more  deli- 
cate sensibilities  are  not  infrequently  striking.  During  this 
period  of  mild  excitement  symptoms  of  fatigue  are  generally 
absent;  the  patients  sleep  but  little;  the  appetite,  as  a  rule,  is 
somewhat  diminished,  though  at  times  the  food  may  be  bolted 
in  fairly  large  quantities. 

Between  these  cases  and  the  severest  forms  of  mania  all 
grades  are  found.  In  some  instances  insane  ideas  predomi- 
nate. The  differential  diagnosis  between  these  cases  and  those 
of  general  paresis  in  its  early  stages  is  frequently  difficult, 
especially  when  occurring  in  comparatively  young  people. 

The  maniacal  stage  in  some  cases  is  characterized  by  an 
absence  of  general  motor  excitement,  the  symptoms  noted 
being  more  purely  psychical.  In  women  the  periods  of  greatest 
excitement  may  coincide  with  the  menstrual  epochs.  The  so- 
called  periodic  psychopathia  sexualis  is  in  many  instances  a 
mild  recurrent  type.  The  mere  periodicity  of  the  recurrence 
is  not  in  any  sense  a  point  of  great  diagnostic  importance. 
The  forensic  importance  of  these  cases  is  referred  to  under 
the  chapter  dealing  with  the  questions  of  legal  responsibility. 
Occasionally  we  meet  with  cases  in  which  there  is  marked  mo- 
tor restlessness  as  well  as  the  compulsion  to  act,  but  the  limita- 
tion and  retardation  of  the  associative  faculties  are  prominent 
features  in  the  symptomatology.  These  patients  represent  the 
examples  of  mania  with  limited  and  delayed  thought — the  un- 
productive mania.  The  emotional  state  may  be  one  of  evident 
pleasure  or  exaltation.  This  group  of  symptoms  in  some  cases 
may  take  the  place  of  the  period  of  true  maniacal  excitement. 
In  others  it  merely  follows  it,  representing  the  stage  of  sub- 
sidence of  the  acute  symptoms  (Stadium  dementiae  or  morise). 


MANIC-DEPRESSIVE    INSANITY 


359 


(2)  States  in  zuhich  the  dominant  symptoms  are  psycho- 
motor inhibition,  mental  depression,  and  retardation  in  the 
association  of  ideas. — The  milder  cases,  hypo-melancholias, 
are  not  infrequently  diagnosed  as  neurasthenia.  As  a  rule,  it 
is  impossible  to  say  when  the  prodromal  period  begins.  The 
symptoms  are  not  specific.  For  a  long  time  the  patient  may 
be  considered  to  be  merely  a  hypochondriac,  and  it  is  only 
when  the  subsequent  stage  occurs  in  which  the  antecedent 
psychic  inhibition  is  contrasted  with  the  motor  restlessness 
and  exaltation  that  a  diagnosis  can  be  made.  In  some  cases 
the  prodromal  period  is  one  in  which  the  dominant  features 
are  slight  motor  restlessness  and  a  group  of  physical  symptoms 
which  suggest  the  very  mildest  form  of  maniacal  excitement. 

Anaesthesias,  more  frequently  paresthesias,  occur.  As  the 
period  of  depression  develops,  the  psychomotor  retardation 
becomes  evident,  and  the  patient  passes  into  a  stuporous  state 
in  which  the  retardation  is  excessive.  At  times  the  patient 
may  become  subject  to  hallucinations.  In  the  milder  cases,  as 
a  rule,  these  are  evanescent  in  character. 

The  occurrence  of  cases  of  pure  mental  depression  with- 
out any  of  the  accompanying  symptoms  of  excitement  are 
exceedingly  rare,  if,  indeed,  they  ever  occur.  The  following 
case  abstract  shows  that,  even  although  symptoms  of  excite- 
ment may  be  slight,  they  are  never  completely  absent : 

Patient,  female,  single,  aged  39.  Two  years  prior  to  admission  she 
had  a  nervous  breakdown  due  to  worry.  Six  months  before  coming  to 
hospital  there  was  a  period  of  improvement  followed  by  nervousness  and 
insomnia.  Religious  fears  and  anxiety  developed.  On  admission  to  the 
hospital  she  was  very  nervous,  slightly  confused ;  there  was  loss  of  appe- 
tite and  insomnia.  Self-accusation  was  noted.  The  patient  affirmed  that 
she  was  a  very  wicked  woman  and  that  she  expected  Almighty  God  to 
strike  her  dead.  The  facial  expression  was  one  of  depression.  The  asso- 
ciation of  ideas  was  slow.  The  tone  of  voice  was  low  and  monotonous. 
There  was  considerable  motor  retardation.  She  retained  insight  into  her 
own  condition.  The  power  of  fixation  and  concentration  was  poor.  Sus- 
piciousness and  fear  were  at  times  marked.  She  was  decidedly  intro- 
spective, and  explained  the  evolution  of  her  insane  ideas  as  follows : 

(1)  That  she  was  an  unconscious  hypocrite,  doing  evil  without  know- 
ing it. 

(2)  That  consciousness  of  innate  evil  had  led  her  to  believe  that  she 
was  an  exceptional  person,  that  no  one  ever  had  been  created  so  bad  as 
herself. 


360  PSYCHIATRY 

(3)  That  as  a  consequence  of  this  unusual  wickedness  she  had  reve- 
lations of  the  devil,  visual  and  auditory. 

(4)  That  she  recognized  that  she  was  a  lost  soul;  that  she  was 
haunted  by  the  awfulness  of  her  prospect  in  the  presence  of  the  evil  spirit, 
as  well  as  the  ideas  of  future  torment. 

(5)  She  affirmed  that  all  these  were  spiritual  phenomena  (auditory  and 
visual   hallucinations). 

Weight  on  admission,  February  13,  1901,  134  pounds.  June  I,  125 
pounds.  In  the  early  part  of  February  motor  restlessness  was  very  marked. 
It  gradually  decreased  until  April,  when  it  passed  away.  All  the  symptoms 
subsided,  and  the  patient  was  discharged  November  23,  greatly  improved ; 
weight  133  pounds. 

The  period  of  excitement  may  occur  either  in  the  prodro- 
mal period  or  in  the  period  of  convalescence,  and  is  not  infre- 
quently in  the  latter  stage  referred  to  merely  as  a  reactive 
hyperemia.  The  duration  of  the  depression  varies.  Instances 
have  been  reported  in  which  it  recurred  every  few  days  with 
great  regularity.  Clinically,  the  majority  of  cases  may  be 
grouped  into  those  with  psychomotor  retardation  and  depres- 
sion accompanied  by  more  or  less  stupor.  Some  of  the  pa- 
tients who  show  signs  of  melancholia  with  motor  restlessness 
(melancholia  agitata)  belong  in  this  group,  while  other  cases 
are  instances  of  dementia  prsecox  or  the  involutional  melan- 
cholias. 

(3)  States  in  which  the  symptoms  of  excitement  and  of 
depression  occur  with  some  degree  of  regularity  and  with  an 
inclination  to  alternate.14"  The  charts  X  and  Y,  taken  from 
Weygandt,  give  a  graphic  indication  of  the  character  and  se- 
quence of  the  recurrences  in  the  cases  commonly  referred  to  as 
instances  of  circular  insanity.  The  curve  below  the  horizontal 
line  indicates  depression,  and  the  one  above  the  period  of  ex- 
citement. Weygandt  affirms  that  in  150  cases  with  marked 
recurrences  20  per  cent,  had  attacks  in  which  the  mixed  char- 
acter of  the  symptoms  predominated.  In  33  per  cent,  this 
was  merely  transitory,  and  was  most  marked  during  the  tran- 


14  Dewey :  A  Case  of  Circular  Insanity  studied  from  Clinical  Differ- 
ential and  Forensic  Stand-points.  Journ.  Araer.  Med.  Assoc,  April  30, 
May  7,  1904. 


MANIC-DEPRESSIVE    INSANITY 


361 


sition  stages.    Marked  deviations  from  this  type  of  the  disease 
were  noted  in  14  per  cent,  of  the  cases. 


Folie,  a  double  forme. 


Continuous  type. 


With  irregular  intervals. 


Q      p     Q     W 


Alternating  form. 


1  u  1  1  1  j  1  ivf  I  1  1 1  1 1  1  ]  ><i  1 1  1 1>  1  1  1  1  1  1  mi 


1895  1896  1897 

From  an  observed  case. 
Chart  X,  showing  periodic  forms  of  manic-depressive  insanity.     (From  Weygandt.) 

(4)  States  in  which  the  affective  fluctuations  become 
less  marked  and  the  patient  shows  a  tendency  to  develop  a 
more  or  less  immobile  systematized  paranoiic  condition}7' — 
The  diagnosis  in  these  cases  can  frequently  be  made  only  with 
considerable  difficulty  and  after  much  time  has  elapsed.  This 
category  includes  some,  if  not  all,  of  the  so-called  recurrent 
paranoias   in   which    during   the   lucid   intervals   there   is    no 


15  Weygandt :  Ueber  die  Mischzustande  des  manisch-depressiven  Irre- 
seins.  Munchen,  1899.  Sollier :  Sur  une  forme  circulaire  de  la  neuras- 
thenic Revue  de  Medecine,  1893,  p.  1909.  Pferdsdorff :  Ueber  intestinale 
Wahnideen  im  manisch-depressiven  Irresein.  Centralbl.  f.  Nervenheilk. 
u.  Psych.,  1904,  Marz,  Nr.  170. 


362 


PSYCHIATRY 


specific  reduction.  In  the  United  States  alienists  are  particu- 
larly indebted  to  August  Hoch  for  his  study  of  this  type  of 
the  disease.  These  cases  may  be  divided  into  two  categories : 
(a)   those  which  develop   out  of  one  of  the  conditions  de- 


t±* 


VM 


itrrm-M 


Chart  Y,  showing  course  in  cases  of  manic-depressive  insanity. 

In  the  above  diagrams  the  black  horizontal  line  indicates  the  period  of  psychomotor  re- 
tardation, the  open  horizontal  line  the  period  of  psychomotor  irritability  or  excitability.  The 
curve  below  the  line  indicates  emotional  depression,  and  above  the  line  indicates  emotional 


excitement.    For  example : 


tional  depression. 


indicates  psychomotor  retardation  and  emo- 


indicates  psychomotor  irritability  and  emotional 


excitement.    The  short  vertical  lines  divide  the  curves  into  weekly  periods.  (From  Weygandt.) 


scribed  as  depressed,  excited,  or  mixed  states,  and  (b)  rare 
instances  in  which  the  paranoiic  condition  is  marked  at  the  out- 
break of  the  alienation. 

Etiology. — Nothing  is  known  in  regard  to  the  dominant 
causes  which  determine  the  character  of  the  attacks.  There  is 
no  satisfactory  hypothesis  that  attempts  to  explain  the  reason 
why  motor  restlessness  and  exaltation  are  the  dominant  feat- 
ures in  one  case  and  in  another  psychomotor  retardation  and 


MANIC-DEPRESSIVE    INSANITY  363 

depression.  Lambranzi 16  examined,  between  1895  and  1901, 
173  cases  in  which  the  diagnosis  of  mania  had  been  made.  Of 
these  individuals  99  were  women  and  74  men ;  48  had  already 
been  under  treatment ;  37  had  a  recurrence  of  the  attack  during 
the  period  of  observation;  15  had  several  attacks,  and  their 
cases  were  diagnosed  as  periodic  psychoses;  5  had  recurrent 
attacks  of  melancholia,  and  were  regarded  as  suffering  from 
circular  insanity.  Of  the  remainder,  after  the  elimination  of 
the  doubtful  cases  in  which  alcoholism,  epilepsy,  or  hysteria 
played  an  important  role  in  the  pathogenesis,  there  were  12 
which  gave  the  clinical  picture  of  mania.  In  157  patients  in 
whom  the  diagnosis  of  melancholia  was  made  27  had  been 
under  treatment  for  a  similar  trouble;  34  had  single  recur- 
rences; 5  a  periodic,  and  4  a  typical  circular  insanity.  The 
remaining  19  cases  had  symptoms  of  mental  depression.  More 
recently  Soukanoff  and  Gannouchkine 17  have  examined  all 
patients  suffering  from  mania  admitted  to  the  Psychiatrical 
Clinic  in  the  University  of  Moscow,  carefully  excluding  all 
cases  in  which  there  were  any  symptoms  of  depression  as  well 
as  all  forms  of  the  circular  insanity.  From  these  observations 
they  came  to  the  conclusion  that  every  acute  psychosis,  whether 
it  be  amentia,  melancholia,  mania,  etc.,  always  has  a  tendency 
to  recur  at  shorter  or  longer  intervals.  Out  of  4434  patients 
admitted  to  the  clinic  between  November,  1887,  and  Septem- 
ber, 1902,  only  40  cases,  16  in  men  and  24  in  women,  were  diag- 
nosed as  mania.  It  was  found  after  a  further  analysis  of 
these  statistics  that  the  symptoms  of  motor  restlessness  and 
exaltation  were  more  apt  to  dominate  the  clinical  picture  in 
women  than  in  men  in  the  proportion  of  2  to  1.  Although  the 
number  of  maniacal  patients  was  less  than  1  to  100,  the  per- 
centage of  cases  of  mental  depression  was  almost  seven  times 
as  great.     Although  the  pure  maniacal  symptoms  according 

16  Lambranzi,  Ruggiero :  Contribute)  alio  studio  della  "  frenosi  maniaco- 
depressiva"  e  della  melancolia  da  involuzione  (Giorn.  de  psichatr.  clin., 
xxx,  No.  2,  3. 

17  Etude  sur  la  manie.  Archives  de  Neurologie,  t.  xv,  Mai,  1903,  No. 
89,  p.  401. 


364  PSYCHIATRY 

to  these  statistics  are  comparatively  rare  in  both  men  and 
women,  the  mental  depression  is  one  of  the  most  frequent 
psychical  disturbances  in  women. 

According  to  Kirn  and  Pick,18  in  the  so-called  circular 
form  of  the  disease  the  character  of  the  first  attack  seldom 
corresponds  with  that  of  the  later  recurrences.  Generally  the 
patient  has  an  attack  of  mania  followed  by  a  period  in  which 
motor  restlessness  and  exaltation  are  the  dominating-  symp- 
toms ;  then  a  lucid  interval  followed  by  an  attack  of  mania  or 
melancholia.  Some  clinicians  affirm  that  the  circular  forms 
always  begin  with  an  attack  of  melancholia.  CloustOn,  how- 
ever, maintains  that  the  symptoms  of  excitement  most  fre- 
quently occur  in  the  initial  seizure.  When  the  attacks  of  de- 
pression and  excitement  are  associated  and  have  reached  a 
maximum  intensity  they  tend  to  recur  at  frequent  intervals 
during  the  rest  of  the  patient's  life. 

The  prognosis  is,  as  a  rule,  bad  in  all  forms  of  periodic 
insanity  in  which  the  individual  attacks  are  severe  and  pro- 
longed. It  is  somewhat  more  favorable  where  the  attacks  are 
shorter  in  duration  and  come  in  groups.  The  duration  of  the 
attacks  may  vary  greatly  from  a  few  hours  to  one  or  two  years. 
Cases  have  been  reported  in  which  the  attacks  lasted  for  six  to 
seven  years. 

The  mental  condition  of  the  patients  during  the  lucid 
intervals  varies.  Cases  have  been  recorded  in  which  frequent 
attacks  have  occurred  during  the  life  of  the  patient,  and  in 
the  intervals  between  the  attacks  the  intelligence  seemed  to 
be  unimpaired.  One  author  mentions  a  patient  who  died  at 
the  age  of  78  and  who  had  suffered  from  recurrent  attacks 
for  forty-four  years,  and  yet  during  the  remissions  had  ex- 
hibited no  trace  of  intellectual  impairment.  The  lowering 
of  the  cortical  functions,  most  frequently  noted  in  these  indi- 
viduals during  a  remission,   does  not,  as  a  rule,  show  itself 


1S  Die  periodischen  Psychosen.  Stuttgart,  1878.  Pick :  Eulenberg's 
Realencyclopadie  d.  gesammten  Heilkunde,  III.  AufL,  Bd.  iv,  p.  665. 
"  Circulares  Irresein." 


MANIC-DEPRESSIVE   INSANITY  365 

in  the  intellectual  sphere.  Generally  there  is  a  certain  degree 
of  emotional  irritability,  a  capriciousness,  marked  egotism,  and 
perhaps  an  impairment  of  the  ethical  sense.  In  some  instances 
a  chronic  state  develops  which  bears  the  marks  either  of  mani- 
acal excitement  or  the  period  of  depression.  Tne  former  is 
occasionally  interspersed  by  periods  in  which  the  motor  rest- 
lessness alternates  temporarily  with  a  brief  period  of  ps)^cho- 
motor  retardation.  In  the  prolonged  cases  of  mental  depres- 
sion the  periods  of  depression  alternate  with  those  of  motor 
restlessness.  These  chronic  cases  need  to  be  studied  more  in 
detail.  The  occurrence  of  well-systematized  insane  ideas  with  a 
lessening  of  affective  fluctuations  is  generally  an  indication  that 
the  attack  will  be  a  protracted  one.  It  is  not  always  possible 
to  say  from  the  intense  character  of  the  excitement  or  the  mere 
depth  of  the  depression  that  the  patient  will  be  a  long  time  in 
convalescing.  In  all  forms  of  this  disease  it  is  very  important 
that  a  careful  record  should  be  kept  of  the  weight  of  the  indi- 
vidual. As  long  as  this  falls,  either  in  the  period  of  depression 
or  excitement,  a  favorable  prognosis  cannot  be  given  even 
if  the  mental  state  of  the  patient  seems  to  show  some  improve- 
ment. As  soon,  however,  as  the  weight  curve  begins  to  rise 
a  favorable  prognosis  may  be  given,  even  if  the  mental  status 
is  apparently  unchanged.  An  example  illustrating  the  im- 
portance of  this  last  point  is  given  in  the  history  of  the  fol- 
lowing case : 

The  patient,  a  man  aged  20,  was  admitted  to  the  Sheppard  and  Enoch 
Pratt  Hospital  November  28,  1903. 

Family  History.- — Negative  for  nervous  and  mental  diseases. 

Personal  History. — No  peculiarity  in  mental  development.  Good  stu- 
dent. History  and  mathematics  favorite  topics  of  study  at  school.  Whoop- 
ing-cough and  measles  when  a  child.  At  the  age  of  15  was  thrown  from  a 
wagon ;  was  unconscious  for  an  hour,  but  made  a  rapid  recovery  and  no 
after-effects  were  noted.  "  Has  been  treated  for  kidney  trouble  since  age 
of  18,  and  has  frequently  had  attacks  of  chills  and  fever,  during  which  he 
was  often  delirious."  Character  previous  to  onset  of  present  illness  has 
been  described  as  at  times  vacillating  and  impulsive. 

Present  Illness. — Relatives  noticed  that  he  had  acted  queerly  for  about 
a  year.  At  times  would  seem  to  be  absent-minded  and  dreaming.  In  the 
spring  of  1903  he  suffered  from  loss  of  appetite,  a  general  feeling  of  malaise, 


366  PSYCHIATRY 

and  some  mental  depression.  These  symptoms  continued  off  and  on  until 
October,  1903,  when  he  became  restless  with  periods  of  reticence,  seclusive- 
ness,  and  irritability.  He  was  easily  confused  and  occasionally  self-accusa- 
tory. A  few  days  prior  to  admission  to  the  hospital  he  began  to  talk  a  great 
deal,  and  "  preached  on  everything  he  had  seen  or  heard."  Later  became 
very  violent,  wanted  to  put  his  father  and  mother  out  of  the  house.  This 
period  of  aggressiveness  was  followed  by  one  of  the  depressed  spells,  which 
lasted  only  a  few  hours,  when  he  again  became  excited,  indulged  in  a  great 
deal  of  profanity,  and  tried  to  whip  one  of  his  uncles.  Patient  was  first 
taken  to  the  city  almshouse,  and  transferred  from  there  on  November  28 
to  the  Sheppard  and  Enoch  Pratt  Hospital.  On  admission  to  the  latter 
institution  it  was  noted  that  he  was  apparently  dazed,  confused,  and 
showed  considerable  motor  restlessness,  but  towards  evening  this  disap- 
peared. On  the  following  day  while  under  examination  he  made  no 
objection  to  being  undressed,  merely  submitting  passively  without  offer- 
ing in  any  way  to  help.  The  general  character  of  the  motor  reactions 
indicated  the  existence  of  slight  psychomotor  retardation.  Attention 
easily  gained,  but  little  power  of  concentration.  Voluntary  conversation 
at  times  limited.  Once  or  twice  without  any  apparent  reason  began  to 
cry  and  complain  of  having  been  cursed  by  some  one  whose  name  he  did 
not  give.  Admitted  that  his  memory  was  somewhat  defective,  but  other- 
wise he  was  "  quite  bright  in  his  mind,"  "  although  sick  of  trying  to  save 
people,"  and  did  not  want  anyone  to  send  him  to  prison.  On  December  3, 
the  patient  was  more  communicative.  His  attention  was  easily  gained  but 
still  lacked  concentration.  He  would  begin  to  describe  an  object  or  to 
give  expression  to  some  ideas,  but  distractibility  was  very  marked,  and 
apparently  he  had  no  goal  in  view.  Emotional  tone  corresponded  with 
mental  state.  Weight,  113  pounds.  Blood-pressure,  130.  On  this  date,. 
December  4,  patient  began  to  show  signs  of  increasing  motor  restlessness 
and  compulsory  speech,  insisting  upon  declaiming  before  patients  and 
attendants. 

December  5.  Markedly  depressed,  with  tendency  to  cry.  Affirmed 
that  his  thoughts  are  audible  so  that  other  people  could  hear  them.  Even 
God  had  heard  them,  otherwise  the  patient  would  have  been  dead  long 
ago.  Remembered  having  been  noisy  during  the  night.  Said  he  could 
not  help  this,  as  he  saw  some  one  rising  from  the  dead.  Declared  that 
unpleasant  thoughts  made  him  cry. 

December  10.  Motor  restlessness  more  marked,  considerable  exuber- 
ance of  spirits.  Danced  and  cut  capers,  tore  his  clothes,  and  was  mark- 
edly impulsive.  At  the  end  of  December  the  patient  had  gained  four 
pounds  in  weight,  but  there  was  no  improvement  in  the  mental  condition. 
On  January  21,  although  there  was  some  general  motor  restlessness 
present,  the  patient's  emotional  tone  was  evidently  one  of  depression. 
While  being  examined,  he  showed  no  tendency  to  talk,  but  when  asked  to 
write  gave  evidence  of  the  existence  of  a  sensory  flight  of  ideas.  Patient's 
condition  has  gradually  improved,  and  with  the  exception  of  the  two  slight 
drops  in  weight  indicated  on  the  chart  there  has  been  a  steady  and  un- 


MANIC-DEPRESSIVE   INSANITY 


367 


interrupted  gain.  The  slight  loss  of  weight  between  February  5  and  12 
was  accompanied  by  a  change  in  the  mental  attitude  of  the  patient,  as 
he  was  angered  and  depressed  by  what  he  thought  was  an  apparent  in- 
attention and  lack  of  sympathy  exhibited  in  his  case  by  a  relative. 


Lbs. 
150 

140 

130 

120 
110 

|-s-I*         =         '-|---|- 

J  _/ 

B 

k 

/ 

/ 

/ 

/ 

^ 

1 

_l 

Weight  chart  in  a  case  of  manic-depressive  insanity.    At  A  and  B  the  patient  was  more 
depressed  than  usual. 

Pathogenesis. — Nothing  is  known  regarding  the  imme- 
diate causes  of  this  disease.  There  is  no  other  form,  however,, 
of  mental  aberration  in  which  the  hereditary  factor  plays  a 
more  important  role.  In  from  80  per  cent,  to  90  per  cent, 
of  the  cases  of  manic-depressive  insanity  the  history  of  insan- 
ity afflicting  the  ascendants  is  well  marked.  Soukhanoff  and 
Gannouchkine,19  as  the  result  of  their  observations,  affirm  that 
women  are  more  inclined  to  suffer  from  depression  than  are 
men  (3:1),  and  that  the  hereditary  factor  plays  a  less  impor- 
tant role  in  the  former  than  in  the  latter.  The  disease  when  it 
once  makes  its  appearance  in  a  family  shows  a  remarkable  ten- 
dency to  reappear  in  the  descendants.  Even  when  a  history 
of  definite  symptoms  of  alienation  cannot  be  obtained  as  having 
occurred  in  the  progenitors,  "  strong  family  idiosyncrasies" 
are  nearly  always  noted.     As  a  rule,  the  majority  of  patients 

19  £tude  sur  la  melancholic     Annales  medico-psychologiques,   Sept.- 
Oct,  1903. 


368  PSYCHIATRY 

who  suffer  from  this  disease  are  delicate.  From  their  earliest 
years  they  have  exhibited  eccentricities  of  character  referable 
to  an  unstable  nervous  system — hypochondriasis,  "  attacks  of 
the  blues,"  sexual  irregularities,  more  or  less  egotism,  a  ten- 
dency to  lie,  etc.,  being  some  of  the  more  common  defects.  The 
importance  of  trauma,  the  acute  infectious  diseases,  meningitis, 
encephalitis,  parturition,  excessive  and  prolonged  physical  and 
mental  strain  have  all  been  emphasized  as  etiological  factors. 

Sufficient  has  already  been  said  to  show  that  the  differen- 
tial diagnosis  in  these  cases  is  frequently  beset  with  many  diffi- 
culties. This  is  particularly  true  in  the  excited  stage.  The 
motor  restlessness  and  exaltation  in  this  condition,  as  a  rule, 
differ  essentially  from  those  observed  in  cases  of  dementia 
prsecox.  In  manic-depressive  insanity  the  patient  is  more  re- 
sponsive to  external  stimuli,  he  is  easily  deflected  and  may  to 
a  certain  extent  be  led.  Each  new  impression  as  it  is  stamped 
upon  the  cortex  gives  birth  to  an  idea  expressed  either  in  speech 
or  action  that  is  the  result  of  the  incident  stimulus.  The  flight 
of  ideas  may  be  distinguished  from  a  mere  hotch-potch,  inas- 
much as  the  latter  by  its  extreme  silliness,  irrelevancy,  numer- 
ous repetitions,  and  reiterations,  is  more  suggestive  of  mere 
automatism.  The  actions  of  the  patients  during  the  stage  of 
maniacal  excitement  are,  as  a  rule,  conditioned  by  the  effect  of 
extra-organic  stimuli.  In  the  earliest  stages  of  the  excitement 
the  diagnosis  is  frequently  extremely  difficult,  as  it  depends 
largely  upon  the  intimate  knowledge  possessed  by  the  observer 
of  the  patient's  idiosyncrasies.  The  maniacal  excitement  may 
be  mistaken  for  the  earliest  toxic  symptoms  produced  by  cocain, 
alcohol,  and  other  drugs  which  give  rise  to  motor  restlessness 
and  a  limited  flight  of  ideas.  In  the  pronounced  cases  the 
mental  exhilaration  of  the  patient  may  simulate  the  incipient 
euphoria  of  general  paresis,  but  in  the  latter  instance  the  ideas 
are  apt  to  be  more  insistent  and  the  self-complacency  of  the 
patient  is  more  exaggerated.  The  recognition  of  the  depression 
in  the  early  stages  or  in  the  milder  forms  of  the  disease  is  even 
more  difficult  than  that  of  manic  excitement.  Not  infrequently 
it  is  extremely  difficult  to  determine  whether  an  actual  psycho- 


MANIC-DEPRESSIVE    INSANITY  369 

motor  retardation  exists.  The  diagnosis  is  rendered  even  more 
difficult  if,  as  is  often  the  case,  depression  is  associated  with 
motor  excitement.  The  subjective  sense  of  insufficiency  of 
which  the  patients  may  complain  is  an  important  sign  during 
the  period  of  depression.  Individuals  so  afflicted  may  regret 
that  they  are  unable  to  work,  or  to  exert  themselves  in  any 
way,  and  may  complain  bitterly  of  the  retardation  and  inhibi- 
tion of  their  mental  processes. 

The  involutional  melancholias  are,  as  a  rule,  to  be  distin- 
guished by  the  greater  tendency  shown  for  the  development 
of  the  systematized  delusions  and  the  absence  of  marked 
psychomotor  retardation  and  delay  in  all  forms  of  thought. 
In  these  cases  the  insane  ideas  are  more  stable.  The  outbursts 
of  anxiety  which  accompany  the  pre-senile  or  senile  depressions 
are  important  factors  in  the  differential  diagnosis  of  these  dis- 
orders. Dementia  prsecox  is  to  be  distinguished  from  manic- 
depressive  insanity  by  the  occurrence  of  mannerisms,  motor 
symptoms,  verbigeration,  isolated  impulsive  acts,  etc.  The 
milder  cases  described  as  cyclothemia  are  not  infrequently 
difficult  to  differentiate  from  neurasthenic  states  in  which  not 
infrequently  there  is  a  mixed  state  of  mild  excitement  with 
subsequent  depression.  Occasionally,  it  is  impossible  to  decide 
for  some  time  whether  a  case  is  one  of  epileptic  mania  or  of 
manic-depressive  insanity.  In  the  former  instance  the  out- 
breaks are  apt  to  be  more  violent,  the  patient  is  much  more 
dangerous,  and  the  typical  flight  of  ideas  in  the  broadest  sense 
is,  as  a  rule,  not  present.  The  occurrence  of  epileptiform  at- 
tacks is  distinctive. 

The  treatment  of  these  cases  is  symptomatic.  What  has 
already  been  said  in  a  general  way  in  reference  to  the  treat- 
ment of  states  of  mania  or  depression  may  be  applied  to  the 
care  of  patients  during  the  attacks  of  manic-depressive  insanity. 
In  the  case  of  a  young  person  it  is  the  duty  of  the  physician  to 
inform  the  parents  or  guardians  that  the  tendency  of  the  disease 
to  recur  is  very  great.  The  life  of  the  afflicted  individual  must 
be  so  ordered  that  all  forms  of  excitement,  physical  or  men- 
tal, are  reduced  to  a  minimum.     If  the  circumstances  permit 

24 


370 


PSYCHIATRY 


an  out-of-door  life  in  the  country,  it  is  to  be  recommended. 
Great  care  should  be  exercised  during  the  onset  of  puberty. 
If  the  patient  becomes  conscious  of  too  great  supervision  of 
all  the  minor  details  of  his  or  her  life,  the  periods  of  mild 
depression  are  augmented  or  the  development  of  a  marked 
hypochondriasis  may  be  generated.  During  the  period  of 
excitement  care  should  be  taken  to  guard  against  the  occur- 
rence of  sexual  irregularities.  The  mildest  cases  may  be  treated 
at  home  provided  the  physician  fully  comprehends  the  nature 
of  the  disorder  and  is  fully  alive  to  the  exigencies  of  the  case. 
The  severer  cases  can  be  handled  much  better  in  an  institution, 
where  a  rest-cure  in  bed  with  massage,  hydrotherapy,  and  a 
light  and  nutritious  diet  can  be  provided. 

As  the  tendency  of  manic-depressive  insanity  to  recur  in 
families  is  very  marked,  marriage  in  the  case  of  individuals  who 
have  once  suffered  from  this  form  of  alienation  is  contra- 
indicated.  During  the  periods  of  excitement  the  prolonged  or 
continuous  baths  are  often  efficacious  in  cutting  short  an  at- 
tack. During  the  periods  of  depression  as  well  as  during  the 
excitement  the  patient  should  be  kept  constantly  in  bed.  Dur- 
ing the  former  phase  as  well  as  during  the  milder  attacks  of 
manic  excitement,  in  moderate  weather,  the  bed  may  be 
wheeled  out  on  the  porch  or  balcony  and  the  patient  kept  in 
the  open  air.  This  is  particularly  desirable  in  cases  of  anaemic 
individuals.  Where  such  a  procedure  is  not  possible  the  win- 
dows in  the  room  may  be  opened  wide  for  several  hours  a  day, 
so  that  the  patient  in  this  way  may  be  given  plenty  of  fresh 
air.  During  the  period  of  depression  the  patient  may  be  put 
in  a  warm  bath,  and  if  there  is  no  contraindication,  the  tem- 
perature of  the  water  may  be  gradually  cooled,  the  patient 
being  carefully  watched  to  see  that  no  ill  effect  follows  this 
procedure.  After  the  bath  massage  and  passive  movements 
are  frequently  of  great  value  in  stimulating  the  superficial  cir- 
culation. In  many  cases  tonics,  such  as  iron,  strychnin,  and 
arsenic,  are  indicated.  In  the  cases  of  manic-depressive  in- 
sanity which  occur  in  plethoric  individuals  it  is  advisable  that 
the  diet  should  be  carefully  restricted.     The  patient  must  be 


>  z. 

if 
£  s. 

2   2 


< 


MANIC-DEPRESSIVE   INSANITY 


371 


closely  watched,  as  such  individuals,  although  apparently 
very  robust,  are  physically  below  the  standard  and  frequently 
show  a  marked  anaemia. 

Pathology. — The  pathological  findings  in  cases  of  manic- 
depressive  insanity  do  not  throw  any  light  upon  the  nature 
of  this  disease.  Patients  do  not  die  from  the  immediate  effects 
of  the  disorder  itself,  but  from  some  intercurrent  affection. 
The  histological  changes  in  the  neural  elements  of  the  central 
nervous  system  are  those  found  in  other  chronic  or  acute  dis- 
eases. Turner  has  described  alterations  in  the  nerve-cell  which 
were  affirmed  to  be  in  a  measure  specific  for  the  so-called  deli- 
rious manias,  but  on  more  careful  investigation  similar  changes 
were  found  to  be  present  in  other  conditions.  Great  care 
should  be  exercised  in  examining  the  central  nervous  system 
and  in  basing  deductions  as  to  the  pathogenesis  of  the  disease 
upon  the  occurrence  at  autopsy  of  cerebral  hyperemias.  Not 
infrequently  the  marked  injection  of  the  vessels  of  the  mem- 
branes and  cortex  is  merely  an  agonal  or  post-mortem  change, 
the  result  of  alterations  in  the  blood-supply  due  to  the  position 
of  the  body.  It  is  true  that  the  maniacal  stage  is  very  often 
associated  with  low  blood-pressure  in  the  peripheral  arteries, 
while  in  the  stage  of  depression  the  reverse  holds  good;  but 
that  the  intracranial  tension  is  either  increased  or  lowered 
can  not  be  decided  from  the  condition  of  the  peripheral  circu- 
lation. Pilcz  20  affirms  that  in  ten  cases  reported  there  were 
no  marked  pathological  changes  found  in  the  central  nervous 
system.  In  seven  cases  scar  tissue  was  reported,  and  in  ten 
instances  other  changes  were  noted.  The  findings  in  the  cen- 
tral nervous  system  in  twTo  cases  reported  by  the  author  were 
practically  negative.  Stoddart 21  has  formulated  the  hypothesis 
that  in  mania  an  irritating  product  is  formed  within  the  cor- 
tical cells,  while  in  melancholia  the  effect  of  the  toxic  agent 
is  paralyzing.  This  same  observer  thinks  that  in  a  few  cases 
of  mania,  in  addition  to  the  poison  originating  within  the 
nerve-cell,  a  toxic  substance  also  occurs  in  the  plasma. 

20  Op.  cit,  and  Beitrage  zur  Klinik  der  period.  Psychosen.    Monatsschr. 
f.  Psych,  u.  Neurol.,  December,  1903. 

21  Stoddart,  W.  H.  B.,  Lancet,  London,  March  5,  1904. 


CHAPTER    XIV 

THE    DEMENTIA    PRyECOX    GROUP  * 

Although  the  various  forms  of  alienation  recognized 
under  this  head  present  a  symptomatology  with  definite  and 
distinctive  features  and  in  a  majority  of  instances  a  terminal 
dementia  that  is  essentially  characteristic,  it  is  not  improbable 
that  dementia  prsecox  does  not  form  a  disease  entity.  The 
clinical  conceptions  that  have  resulted  in  this  assignment  of 
cases  have  been  of  comparatively  slow  growth.1  As  will  be 
seen  later,  this  group  of  symptom-complexes  is  formed  by  the 
union  of  several  clinical  types  of  alienation  that  have  hitherto 
been  considered  distinct.  Among  the  more  important  of  these 
are  the  cases  originally  described  by  Kahlbaum  as  instances  of 
catatonia,  a  psychosis  considered  by  him  from  a  diagnostic  and 
prognostic  stand-point  to  be  a  disease  entity.2 

In  his  classical  monograph  catatonia  was  defined  as  a 
brain  disease  characterized  by  cyclic,  alternating  periods  of 
melancholia,  mania,  stupor,  confusion,  with  associated  motor 
disturbances,  and  terminating  in  dementia.  From  this  clinical 
picture  one  or  more  of  these  symptoms  may  be  absent.  The 
prognosis  was  admitted  to  be  favorable  in  some  cases ;  in  others 
death  might  occur  during  attacks  of  catatonic  rigidity  and  ex- 
citement. Remissions  were  infrequent  and  the  hereditary 
factor  was  considered  unimportant.  Kahlbaum  called  particu- 
lar attention  to  what  he  considered  to  be  distinctive  features  of 
the  catatonic  symptoms.  Neisser  3  emphasized  the  necessity 
of  considering  the  clinical  picture  as  a  whole  as  definitely  char- 

*Arndt :  Ueber  die  Geschichte  der  Katatonie.  Centralbl.  f.  Nerven- 
heilk.  u.  Psych.,  1902,  p.  81. 

2  Kahlbaum :  Ueber  das  Spannungsirresein.  Vortrag  auf  der  Natur- 
forscherversammlung.  Ref.  Archiv.  f.  Psych.,  ii,  1875.  Kahlbaum : 
Die  Katatonie.     1869. 

3  Neisser,  C. :    Die  Katatonie,  1887. 

372 


DEMENTIA    PRECOX 


373 


acteristic,  and  did  not  lay  great  stress  upon  the  diagnostic  value 
of  individual  symptoms.  Prior  to  the  appearance  of  Kahl- 
baum's  monograph  on  catatonia,  Hecker 4  had  described  a 
group  of  cases  in  which  the  mental  symptoms  developed  about 
the  time  of  puberty  in  individuals  hereditarily  predisposed 
towards  insanity.  The  outcome  in  these  cases  was  a  termina- 
tion in  a  similar  characteristic  dementia.  These  observations 
were  confirmed  by  Hack  Tuke  5  and  Fink.6  In  1886  Schiile 
affirmed  in  words  that  have  become  classic  that  of  those  heredi- 
tarily predisposed  individuals  who  are  "  wrecked  on  the  cliffs 
of  puberty,"  some  become  hebephrenics,  while  others  are 
afflicted  with  an  acute  dementia.  For  this  latter  group  he 
suggested  the  name  dementia  praecox. 

In  1890  A.  Pick,  basing  his  observations  upon  those  of 
Kahlbaum,  came  to  the  conclusion  that  hebephrenia  was  a  form 
of  dementia  praecox.  Under  this  latter  term  Pick  included  the 
class  of  diseases  beginning  at  puberty  with  a  quiet  onset  and 
ending  in  a  progressive  dementia. 

In  1892  Daraszkiewicz,  under  the  influence  of  Tschisch 
and  Kraepelin,  broadened  the  conception  of  hebephrenia  so  that 
the  severe  and  protracted  cases  were  grouped  together  with  the 
shorter  and  milder  instances  described  by  Hecker.  Thus  the 
bridge  was  formed  between  the  two  groups.  It  was  affirmed 
that  the  marked  apathetic  dementia  developed  either  insidiously 
or  followed  periods  of  acute  excitement.  It  is  thus  apparent 
that  the  genesis  of  the  present  views  regarding  hebephrenia  was 
in  a  measure  determined  by  the  increased  emphasis  placed  upon 
the  prognosis.  The  possibility  of  uniting  the  two  disease 
groups  was  first  definitely  suggested  by  Kraepelin,  who  in  the 
sixth  edition  of  his  text-book  brought  together  the  various 
forms  of  alienation  which  will  be  described  under  this  head. 


4  Hecker :     Hebephrenie.      Virchow's    Archiv.    f.    path.    Anat,    1871, 
Bd.  lii. 

5  Hack  Tuke:    A  Manual  of  Psychological  Medicine,  1879,  p.  345. 

6  Fink :     Ein    Beitrag    zur    Kenntniss    des    Jugendirreseins.      Allgem. 
Ztschr.  fur  Psych.,  1881,  Bd.  xxxvii,  S.  498. 


374  PSYCHIATRY 

He  admits  that  other  names,  such  as  the  demenza  primitiva  of 
the  Italians  or  the  dementia  simplex  of  Riger,  may  have  cer- 
tain advantages.  Quite  recently7  the  objections  to  the  use  of 
the  name  dementia  prsecox  as  a  general  term  have  been  more 
definitely  formulated. 

The  fact  that  within  the  near  future  certain  types  of  cases 
now  described  as  dementia  praecox  may  be  taken  out  of  this 
group  does  not  detract  from  the  importance  in  clinical  psy- 
chiatry of  the  formulation  of  those  conceptions  upon  which  the 
present  clinical  analysis  is  based.  The  fact  cannot  be  too 
strongly  emphasized  that  in  studying  this  psychosis  too  much 
stress  should  not  be  laid  upon  the  individual  symptoms  pre- 
sented by  a  patient  at  any  one  period  of  the  disease.  It  is  the 
study  of  the  condition  as  a  whole,  including  the  onset,  course, 
termination,  and  general  symptomatology,  which  promises  the 
best  practical  results.  Little  progress  was  made  in  the  study  of 
dementia  paralytica  so  long  as  clinicians  were  satisfied  with 
simply  grouping  together  the  symptoms  which  occurred  at  any 
given  period  of  the  disease  without  an  equal  regard  for  the 
known  facts  connected  with  the  etiology,  termination,  and 
prognosis  as  well  as  with  the  clinical  course. 

The  triple  clinical  division  suggested  by  Kraepelin — 
namely,  the  hebephrenic,  catatonic,  and  paranoiic  forms  of  the 
disease — is  fairly  satisfactory  if  the  attempt  at  differentiation 
is  not  pushed  to  the  extreme.  Little  is  to  be  gained  by  the 
efforts  sometimes  made  to  distinguish  too  sharply  between 
these  groups,  as  many  of  the  symptoms  are  common  to  all  three 
forms.  Until  more  is  known  regarding  the  natural  history  of 
this  disease  it  is  ill-advised  to  try  to  adhere  to  a  too  rigid 
clinical  classification. 

The  majority  of  the  cases  develop  between  the  twentieth 
and  thirty-eighth  years,  although  competent  observers  have  re- 
ported the  outbreak  of  the  symptoms  before  the  fifteenth  and 
as   late  as   the  fiftieth   year.      The  periods   of   puberty   and 


7  Sommer,  Robert :    Beitrage  zur  Psychiatrische  Klinik.     Marburg,  Bd. 
i,  Heft  4- 


DEMENTIA    PRECOX 


375 


adolescence  are  unquestionably  the  times  at  which  the  majority 
of  the  cases  develop.  But  it  leads  to  unnecessary  confusion  if 
the  possibility  of  the  occurrence  of  cases  at  later  periods  of  life 
is  denied.  The  importance  of  this  fact  is  more  generally  recog- 
nized by  Continental  writers  than  by  English  and  American 
alienists.  The  onset  of  the  disease  is  frequently  insidious,  owing 
to  the  so  commonly  slow  progression  in  the  earlier  stages  of  its 
development  no  less  than  to  the  protean  character  of  the  symp- 
toms. There  is  no  other  form  of  alienation  in  which  an 
intimate  knowledge  of  the  individual  is  of  greater  importance 
as  an  aid  in  establishing  the  diagnosis  at  an  early  period  of  the 
disease  than  in  dementia  prsecox.  While  it  is  incumbent  upon 
the  alienist  to  recognize  the  malady  early  in  its  course,  the  fact 
should  never  be  lost  sight  of  that  the  continual  striving  to  dis- 
cover symptoms  supposed  to  be  of  specific  diagnostic  value  may 
be  carried  to  an  extreme.  In  many  instances  the  signs  of 
mental  aberration  may  be  obvious  for  a  considerable  period 
of  time  prior  to  the  appearance  of  symptoms  now  generally 
recognized  as  distinctive  of  this  psychosis. 

Cases  with  an  acute  onset  are  not  infrequently  reported, 
but  it  is  extremely  doubtful  whether  such  actually  occur.  In 
many  instances  the  apparently  sudden  onset  is  found  on  closer 
examination  to  be  merely  an  exacerbation  of  previously  exist- 
ing symptoms. 

For  example,  a  young  man  came  under  observation  in  the  dispensary 
of  the  Johns  Hopkins  Hospital  giving  the  following  history :  The  patient 
affirmed  that  he  had  felt  perfectly  well  until  a  few  days  before  his  mar- 
riage, but  had  then  become  excessively  nervous.  The  day  following  this 
event  he  went  off  with  several  friends  and  drank  to  excess,  although  he  did 
not  become  intoxicated.  He  came  home  that  night,  complained  of  not 
sleeping  well,  and  the  next  morning  on  awakening  suddenly  sprang  out  of 
bed,  seized  his  wife  by  the  throat,  and  almost  choked  her  to  death.  He 
threatened  to  kill  several  members  of  the  family  who  tried  to  quiet  him. 
Although  conscious  of  what  he  had  done,  he  was  unable  to  assign  any 
motive  for  his  acts  of  violence  and  was  willing  to  admit  that  they  might 
be  considered  those  of  an  insane  person.  The  overwhelming  power  of 
the  impulses  was  recognized  by  the  patient.  Gradually  these  obsessional 
acts  ceased,  but  the  conduct  of  the  patient  was  so  eccentric  that  he  was 
advised  to  come  to  the  Sheppard  and  Enoch  Pratt  Hospital  for  treatment. 


376  PSYCHIATRY 

Although  the  history  of  the  case  given  by  the  family  at  first  suggested  the 
possibility  of  an  acute  onset,  more  careful  inquiry  elicited  the  fact  that  the 
patient  had  exhibited  mental  aberration  for  a  considerable  period  of  time 
prior  to  this  outbreak.  The  subsequent  development  of  the  case  proved 
it  to  be  one  of  dementia  prsecox. 

Another  instance  was  that  of  a  young  woman  24  years  of  age  who  was 
said  to  have  been  perfectly  sane  until  she  had  an  acute  outbreak  of  mania. 
Later  it  was  discovered  that  the  patient  for  years  had  been  decidedly  neu- 
rotic. She  had  always  been  painfully  shy  and  over-particular  regarding 
her  dress.  She  was  described  as  being  impulsive  at  times  and  emotionally 
unstable. 

In  the  early  stages,  particularly  in  young  girls,  attacks  of 
migraine  may  precede  or  usher  in  the  symptoms.  Either  prior 
or  subsequent  to  these  attacks  of  pain  there  is  some  mental 
depression.  Occasionally  the  early  symptoms  are  referred  to 
an  acute  attack  of  some  disease,  such  as  influenza,  typhoid 
fever,  scarlet  fever,  etc.  Although  it  is  probable,  then,  that 
dementia  prsecox  does  occur  in  individuals  who  until  the  time 
of  onset  have  shown  no  sign  of  mental  deterioration,  too  great 
emphasis  can  not  be  put  upon  the  necessity  of  careful  inquiry, 
not  only  regarding  the  patient's  personal  peculiarities  or  idio- 
syncrasies, but  also  as  to  the  nature  of  the  environment  and 
antecedents  prior  to  the  onset  of  the  attack. 

The  prodromal  symptoms  usually  extend  over  a  period  of 
years.  Children  who  have  given  every  promise  of  a  normal 
mental  development  may  in  the  first  years  of  adolescence  show 
evidences  of  a  gradual  progressive  mental  decline.  This  de- 
terioration may  be  so  slow  and  yet  so  widespread  that  it  is 
difficult  for  a  long  time  to  recognize  special  defects  involving 
separate  functions.  Irregularities  in  the  emotional  life  nearly 
always  accompany  the  intellectual  decay.  Individuals  who  have 
never  displayed  marked  emotional  disturbances  until  the  onset 
of  neurasthenic  symptoms  and  then  without  apparent  cause 
give  evidence  of  constantly  recurring  outbreaks  of  temper  on 
little  or  no  provocation  should  be  kept  under  close  supervision. 
Such  patients  not  infrequently  resort  to  unprovoked  violence, 
and  then  after  the  act  is  committed  express  regret  for  their 
conduct,  but,  nevertheless,  true  penitence  is  not  observed.  The 
development  of  these  symptoms  should  at  once  awaken  sus- 


DEMENTIA    PRECOX  377 

picion.  Cases  not  infrequently  come  under  observation  in 
which  impulses  seem  to  replace  all  motives.  The  emotional 
storms  which  are  occasionally  exhibited  early  in  the  develop- 
ment of  these  cases  are  essentially  different  from  those  common 
to  cases  of  hysteria  or  neurasthenia.  In  the  former  there  is 
an  explosive  violence  entirely  without  motive  and  the  event 
may  be  isolated  and  soon  forgotten;  whereas  in  the  latter 
group  of  cases  an  apparent  motive  for  the  excitation  of  feeling 
may  almost  always  be  found  and  is  generally  associated  with 
a  period  of  hypochondriacal  depression.  The  acts  of  violence 
due  to  an  emotional  storm  awaken  in  the  neurasthenic  a  feeling 
of  repentance,  but  the  sense  of  contrition  in  patients  suffering 
from  dementia  prsecox  is  entirely  superficial.  The  emotional 
impulses,  having  the  character  of  obsessions,  which  not  infre- 
quently crop  up  during  the  prodromal  period,  are  apt  to  be 
transitory  and  evanescent.  A  young  woman  without  the 
slightest  reason  to  fear  such  an  event  hears  a  step  on  the  stairs, 
fears  that  an  intruder  will  force  himself  into  her  room,  gives 
vent  to  an  apparent  emotional  outbreak,  which  passes  away 
as  quickly  as  it  came  and  the  incident  is  promptly  forgotten. 
Every  sensory  stimulus  at  times  seems  to  awaken  the  starting- 
point  for  a  new  chain  of  disconnected  heterogeneous  ideas. 
There  is  an  apparent  incoordination  as  well  as  disorganiza- 
tion of  thought.  Local  systematized  delusions  seldom  develop 
early  in  the  disease  except  in  the  paranoiic  form.  Not  infre- 
quently, however,  various  disturbances  of  sensation  may  occur. 
Early  in  the  disease  patients  complain  of  singing  in  the  ears, 
"  strange  sounds"  in  the  head,  pistol  shots,  bright  flashes  of 
light,  or  the  like.  Olfactory  hallucinations,  particularly  of  an 
unpleasant  character,  are  not  infrequent.  One  meets  with 
psycho-anaesthesias  having  the  character  and  distribution  of 
purely  functional  disorders.  Paresthesias  are  less  common. 
At  first  the  disturbances  in  sensation  may  be  practically  un- 
noticed by  the  patient  until  his  attention  is  directed  to  them. 
Gradually  the  tendency  to  explain  their  occurrence  becomes 
more  apparent.  Psychic  hallucinations  frequently  occur.  Their 
importance  in  the  early  stages  of  the  disease  has  recently  been 


378  PSYCHIATRY 

emphasized  by  Lugaro.8  This  observer  affirms  that  in  cases  of 
dementia  precox,  particularly  in  the  paranoiic  forms  of  the 
disease,  the  pseudo-hallucinations  are  frequently  met  with. 
Real  hallucinations  are  either  very  infrequent  or  do  not  occur 
at  all.  The  memory  is  well  preserved.  The  power  of  ideation 
is  unimpaired,  although  there  is  a  marked  disturbance  in  the 
sequence  and  relationship  of  the  products  of  thought.  The 
disturbed  mental  action  consists  largely  in  the  abnormal  elabora- 
tion of  the  voluntary  impulses.  Arrested  impulses  dominate, 
as  it  were,  the  field  of  psychic  activity.  The  psycho-pathology 
of  these  cases  may  be  reduced  fundamentally  to  a  disturbance  in 
the  primary  elaboration  of  stimuli,  volitional  impulses,  etc.,  of 
which  pseudo-hallucinations  are  correlative  phenomena.  The 
anomalies  in  the  organic  sensations,  particularly  the  visceral, 
are  noticeable  in  the  very  earliest  stages  and  are  frequently 
associated  with  the  occurrence  of  the  epigastric  voices,  etc. 

In  addition  to  psychic  hallucinations  insane  ideas  are  fre- 
quently met  with.  Except  in  the  paranoiic  forms  of  the  disease, 
systematization  is,  as  a  rule,  not  well  marked.  The  ideas,  as  ex- 
pressed by  the  patient,  show  plainly  the  marked  disorganization 
in  connected  thinking.  The  emotional  tone  of  the  patient  when 
describing  these  ideas  is,  as  a  rule,  one  of  apathy,  broken  only 
by  acts  which  are  more  frequently  the  result  of  mere  impulse 
than  the  consequence  of  the  dominating  force  of  the  ideas.  In 
some  cases,  particularly  those  in  which  the  disease  progresses 
slowly,  hypochondriacal  ideas  are  present.  The  patients  affirm 
that  changes  have  taken  place  in  their  internal  organs,  that 
they  are  losing  their  minds,  that  their  energy  is  fast  disappear- 
ing, that  they  are  unable  to  arouse  themselves  to  action.  At 
times  megalomania  may  develop;  the  type,  however,  is  essen- 
tially different  from  that  seen  in  dementia  paralytica.  The 
silly  exaggerations  are  prominent.  The  ideas  expressed  are 
grotesque,  bizarre,  and  sometimes  suggested  by  the  environ- 
ment.    An  event  or  an  object  is  mentioned  by  a  patient,  and 


8  Lugaro,   E. :     Sulle   pseudo-allucinazioni    (allucinazioni   psichiche   di 
Baillarger).     Riv.  d.  Patologia  nervosa  e  mentale,  vol.  viii,  fasc.  I  and  2. 


DEMENTIA    PRECOX 


379 


coupled  with  this  there  is  an  insane  idea  entirely  irrelevant,  its 
presence  having  apparently  been  suggested  by  mere  spatial  or 
time  contiguity. 

Sometimes  patients  complain  of  receiving  electric  shocks 
concerning  the  nature  of  which  they  may  develop  vague  sus- 
picions, affirming  that  they  have  been  given  to  them  by  certain 
individuals.  In  the  early  stages  these  phenomena  are  recog- 
nized as  abnormal.  Occasionally  to  the  imperative  conceptions 
exaggerated  ideas  may  be  added.  The  patients  complain  that 
they  can  not  get  rid  of  these  feelings,  although  occasionally  they 
admit  their  inability  to  reason  logically  concerning  the  occur- 
rence of  these  phenomena.  Some  affirm  that  the  repetition  of 
these  sensations  or  the  persistence  in  the  field  of  consciousness 
of  an  imperative  conception  will  in  time  compel  them  to  do  or 
say  things  of  which  they  will  be  ashamed.  The  majority  of 
the  patients  do  not  suffer  great  mental  anguish.  This  is  in  a 
measure  characteristic.  There  is  more  or  less  apathy.  Emo- 
tional storms  may  gather,  break,  and  disappear,  leaving  the 
patient  in  a  state  of  apparent  indifference. 

Among  the  cases  of  dementia  prsecox  which  are  found 
among  dispensary  patients  a  number  give  a  history  of  attacks 
of  mental  depression  occurring  early  in  the  disease.  As  a  rule, 
these  periods  of  depression  are  not  accompanied  with  hypo- 
chondriacal symptoms.  The  patients,  when  they  are  asked  to, 
assign  a  reason  for  their  depression,  but  if  left  to  themselves 
are  listless  and  apathetic.  A  conscientious,  hard-working 
student  becomes  mentally  depressed.  He  affirms  that  he  has 
been  derelict  in  the  performance  of  his  duties,  is  most  persistent 
in  his  declaration  that  his  only  chance  to  succeed  in  life  has 
been  thrown  away.  The  affirmation  is  made  and  persistently 
adhered  to,  but  the  statement  lacks  any  of  the  earnestness  that 
carries  conviction  with  it. 

In  nearly  all  cases  there  is  a  general  blunting  of  the 
emotional  tone.  This  is  very  characteristic.  The  patients  be- 
come indifferent  to  their  most  intimate  friends  as  well  as  to 
members  of  their  family.  Occasionally  in  the  earlier  stages  of 
the  malady  appreciation  of  this  change  is  noted  by  the  patients 


380  PSYCHIATRY 

themselves.  Not  only  is  there  marked  impairment  of  the 
patient's  sympathies  and  affections,  but  at  times  a  paradoxical 
reaction  in  the  objective  expression  of  the  feeling  tone  occurs. 
Stransky  9  has  emphasized  the  importance  of  the  incongruity 
in  the  affective  state  between  the  ideation  and  the  emotional 
reaction  (thymopsyche  and  noopsyche).  This  symptom  is  in- 
dicative of  dissociative  incoordination  of  the  cortical  functions 
— an  intrapsychic  ataxia.  Patients  not  infrequently  indulge 
in  buffoonery  even  while  they  affirm  that  they  feel  depressed 
and  sad.  The  exaltation  which  occurs  is  essentially  different 
from  that  of  the  maniacal  patient.  The  individual  is  silly, 
"  mad  as  a  March  hare,"  and  gives  outward  expression  to  the 
intellectual  as  well  as  emotional  impairment.  The  humor,  wit, 
and  vivacity  sometimes  noticeable  in  cases  of  excitement  due  to 
alcohol  or  marking  the  early  stages  of  manic-depressive  in- 
sanity are  lacking.  The  precocious  dement  is  indifferent,  lack- 
adaisical, and  at  times  singularly  impulsive  and  impetuous  with- 
out being  passionate. 

The  synchronous  appearance  of  a  slow  psychical  reaction, 
very  difficult  to  distinguish  from  the  psychomotor  retardation 
in  the  period  of  depression  in  manic-depressive  insanity  with 
mental  apathy,  when  taken  in  conjunction  with  other  symptoms, 
is  of  diagnostic  importance.  This  phenomenon,  recently  de- 
scribed by  Dunton,10  has  been  noted  during  the  early  stages  of 
the  disease  in  a  comparatively  large  number  of  cases.  There 
seems  to  be  little,  if  any,  difficulty  in  the  transference  of  either 
afferent  or  efferent  stimuli,  but  the  working  up  and  elaboration 
of  impulses  after  their  reception  is  apparently  more  difficult  than 
normal.  If  a  patient  in  this  state  is  questioned,  not  infrequently 
two  or  three  seconds  elapse  before  there  is  any  objective  evi- 
dence of  an  attempt  to  respond.  Then  the  reply  is  given,  gen- 
erally in  a  low,  monotonous  tone.     By  careful  examination 


"Stransky:      Zur     Kenntniss    gewisser    erworbener     Blodsinnformen. 
Jahrbiicher  f.  Psych,  u.  Neurol.,  Bd.  xxiv,  Heft  I. 
30  Am.  Journ.  Insan.,  vol.  lix,  No.   i,  1902. 


DEMENTIA    PFLECOX  381 

evidence  may  be  obtained  that  there  is  no  delay  in  the  trans- 
mission of  the  impulse  to  the  cerebral  cortex,  and  there  is  no 
subjective  sense  of  deficiency  such  as  occurs  in  the  period  of 
depression  when  the  phychomotor  retardation  is  marked.  This 
preservation  of  the  so-called  primary  sensations  is  character- 
istic of  nearly  all  cases  of  dementia  prsecox  in  the  earlier  as  well 
as  in  the  advanced  stages  of  the  disease.  The  fact  that  the 
conduction  of  sensory  impulses  from  the  periphery  to  the  centre 
is  rapid  and  apparently  normal  favors  the  occurrence  of  various 
forms  of  hallucination.  The  orientation,  as  a  rule,  both  for 
time  and  place,  is  not  seriously  affected,  although  patients  may 
affirm  that  they  do  not  know  where  they  are.  In  some  cases 
this  is  due  to  the  apathy  which  exists,  but  in  others  it  is  merely 
an  expression  of  the  patient's  desire  to  be  left  alone.  Another 
cause  for  the  apparent  disorientation  occasionally  met  with  is 
the  consciousness  the  patient  has  of  subjective  difficulties  in 
formulating  his  ideas.  This  gives  rise  to  a  marked  disinclina- 
tion to  speak.  Patients  realize  their  inability  to  carry  through 
to  its  logical  conclusion  a  train  of  thought  and  therefore  refuse 
to  talk.  This  disinclination  is,  as  a  rule,  in  the  early  stages  due 
to  two  factors  :  first,  an  appreciation  of  the  subjective  difficulty 
in  the  association  of  ideas;  and,  second,  the  emotional  state 
engendered  by  hallucinations  or  illusions  gives  birth  to  sus- 
piciousness and  a  consequent  reticence.  This  symptom  is  not 
infrequently  met  with  in  the  earlier  stages,  but  becomes  much 
more  marked  as  the  disease  progresses.  The  antagonism 
aroused  by  interference  from  without  varies  in  different  cases. 
In  the  catatonic  form  of  the  disease  this  so-called  negativism 
is  well  marked.  The  passive  resistance  to  all  forms  of  inter- 
ference offered  by  the  patient  in  the  later  stages  is  motiveless 
and  purely  capricious,  although  at  first  it  may  be  the  result  of 
an  insane  idea.  The  genesis  of  these  refractory  states  has  been 
discussed  in  the  first  part  of  the  book.  The  absence  of  a  well- 
defined  motive,  the  disorganization  of  connected  thinking,  and 
the  anomalous  emotional  state  are  the  factors  that  are  respon- 
sible for  the  actions  of  the  patient.     In  the  earlier  stages  not 


382  PSYCHIATRY 

infrequently  a  motive  is  given  by  the  patient  for  his  actions. 
Gradually  this  vanishes  and  his  conduct  becomes  aggressively 
resistive  in  response  to  all  stimuli.  He  refuses  to  speak  or,  if 
he  does,  gives  audible  expression  to  his  feelings  in  as  few  words 
as  possible.  He  refuses  to  look  the  examiner  in  the  face,  closes 
his  eyes,  and  may  struggle  violently  to  get  away  from  the 
physician  or  attendants.  In  the  exaggerated  cases  the  patients 
cover  themselves  up  with  blankets,  or  hide  under  the  bed,  in 
the  closets,  in  out-of-the-way  nooks  and  corners,  even  refusing 
nourishment  and  refraining  from  voiding  urine  or  evacuating 
their  bowels  until  actually  compelled  to  do  so. 

In  addition  to  negativism,  stereotypies  of  attitude  and 
action  are  in  a  measure  characteristic.  As  has  already  been 
said  in  Section  I,  a  motive  or  an  insane  idea  is  primarily  the 
inciting  factor.  Gradually  this  idea  disappears  and  the  move- 
ments crystallize  and  remain  permanent.  The  limitations  in 
the  field  of  consciousness  and  the  tendency  of  physiological 
processes,  when  once  initiated,  to  persist  are  the  factors  which 
give  rise  to  these  symptoms.  In  the  earlier  stages  the  stereo- 
typies are  sometimes  difficult  to  differentiate  from  tics.  An 
example  of  this  was  seen  in  the  case  of  a  man  who  came  under 
observation  in  the  Johns  Hopkins  Hospital  Dispensary  and 
proved  to  be  suffering  from  one  of  the  slowly  dementing  forms. 
He  was  accustomed  at  every  few  steps,  as  he  walked,  to  rub 
the  calf  of  the  right  leg  with  the  toes  of  the  left  foot.  When 
asked  why  he  did  this  the  patient  affirmed  that  his  leg  itched, 
but  it  was  obvious  that  while  a  parsesthesia  might  originally 
have  been  the  cause  of  this  stereotyped  movement,  later  it  had 
become  automatic.  The  stereotypies  of  movement  may  affect 
the  extremities  and  the  face.  Not  infrequently  patients  make 
curious  grimaces,  grin  in  a  stereotyped  manner,  pucker  up  their 
lips  (the  snouting  cramp),  make  kissing  sounds,  etc.  The 
habits  of  the  patient  prior  to  the  onset  of  the  disease  in  a 
measure  determine  the  character  of  the  stereotypies,  the  move- 
ments which  are  the  most  familiar  to  him  showing  the  greatest 
tendency  to  recur.    The  muscles  of  the  trunk  may  be  similarly 


DEMENTIA    PRECOX  383 

affected.  Patients  gesticulate  or  assume  strange  theatrical 
attitudes.  Their  gait  becomes  stiff,  pantomimic,  in  a  measure 
pathognomonic.  The  speech  is  changed,  but  at  first  only  occa- 
sional eccentricities  attract  attention.  The  vocabulary  is  limited. 
The  words  used  show  a  remarkable  degree  of  precocity,  are 
strange  and  outlandish.  There  is  a  tendency  to  repeat  certain 
words  and  phrases.  In  the  advanced  stages  of  the  disease  the 
repetition  of  senseless  syllables  is  more  or  less  habitual.  There 
is  no  difficulty  in  the  mechanism,  but  merely  in  the  forms  of 
expression.  These  are  stilted,  quixotic,  fantastic,  incoherent, 
and  often  extremely  silly.  At  times  the  patients  interject  a 
few  senseless  syllables  and  then  return  for  an  instant  to  the 
conversation  only  to  relapse  again  into  utter  foolishness.  As 
the  disease  progresses  the  incoherence  and  silliness  become 
more  and  more  marked,  and  we  often  have  merely  a  verbal 
hotch-potch  or,  as  Forel  has  termed  it,  a  word-salad  (Wort- 
salat). 

The  eccentricities  and  mannerisms  of  speech  are  dupli- 
cated in  writing;  the  tendency  to  repeat  words,  syllables,  and 
phrases  is  very  marked.  The  example  given  in  Chapter  III, 
page  33,  shows  an  attempt  made  by  the  patient  to  write  out 
an  account  of  her  physical  condition. 

Not  infrequently  cases  of  mirror  writing  are  reported. 
Patients  not  infrequently  give  expression  to  their  thoughts 
either  audibly  or  in  writing  in  the  form  of  doggerel.  The 
style  of  the  verse  is  stilted,  bombastic,  or  inordinately  foolish. 
In  the  later  stages  of  the  disease  the  speech  may  be  limited  to 
the  mere  repetition  of  a  few  words  or  senseless  syllables. 

Another  important  symptom  which  frequently  occurs, 
sometimes  in  the  earlier  as  well  as  in  the  later  stages  of  the 
disease,  is  the  grotesque  irrelevancy  exhibited  in  replying  to 
questions  (Paralogia,  Vorbeireden).  This  symptom-complex 
was  first  described  by  Ganser  1X  and  consists  in  the  apparent 

"Ueber  einen  eigenartigen  hysterischen  Dammerzustand.  Vortrag  ge- 
halten  am  23.  October,  1897,  in  der  Vers,  der  mitteldeutschen  Psychiatr.  u. 
Neurologen  in  Halle.     Arch.  f.  Psych,  u.  Nervenkrankh.,  xxx,  S.  633. 


384  PSYCHIATRY 

inability  of  the  patient  to  answer  directly  or  satisfactorily  the 
simplest  questions.  With  the  exercise  of  a  little  care  it  is  pos- 
sible to  elicit  the  fact  that  patients  frequently  retain  a  fair 
degree  of  comprehension  of  what  is  asked  them,  but  the  reply 
is  disconnected  and  inapposite  to  a  degree.  Although  an  ap- 
parent effort  is  spasmodically  made  to  answer  the  question,  the 
patient  seems  unable  to  focus  directly  upon  the  essential  point 
in  his  reply. 

Example. — Female,  single,  aged  28.  The  first  symptoms  of  alienation 
were  noted  several  years  ago.  The  present  attack  began  in  1900.  She  felt 
the  attack  coming  on  and  tried  to  fight  against  it.  There  were  alternating 
periods  of  depression  and  excitement,  impulsive  acts  and  marked  dementia. 
The  patient's  present  condition  is  such  that  she  has  to  be  carefully  watched  ; 
she  is  very  impulsive  and  erratic ;  will  suddenly  jump  up  from  her  chair  and 
walk  in  an  aimless  way  up  and  down  the  wards.  She  has  struck  patients 
and  attendants  and  is  unable  to  feed  herself.  The  primary  sensations  are 
well  preserved.  When  questioned  she  occasionally  gives  a  prompt  reply, 
showing  that  there  is  no  obstruction  in  the  afferent  tract.  At  other  times 
the  question  has  to  be  repeated  several  times  before  it  is  apprehended. 
She  makes  an  occasional  low  whining  sound,  is  continually  smacking  her 
lips  as  if  kissing  some  invisible  person.  Some  of  the  questions  and  answers 
are  as  follows:  Q.  How  are  you?  A.  I  am  tolerable,  I  am  sick,  I  need  a 
care,  I  need  to  go  to  heaven.  Q.  Where  do  you  think  you  are?  A.  I  do 
not  know.  Oh,  yes,  I  am  here,  I  am  here  on  the  bed.  Q.  How  long  have 
you  been  here?  A.  I  have  been  here  a  long  time — already — I  want  the 
Bible  in  my  hands.  Q.  What  do  you  want  in  your  hands?  A.  I  guess  it 
would  be  lilies.  Oh,  no,  she  must  not ;  oh,  yes,  the  Bible.  Hand  me  the 
paper  and  the  pencil,  let  me  write,  write  the  other  way.  Won't  you  please 
send  for  a  watermelon?  That  would  do  me  good.  I  want  some  water. 
The  patient  was  asked  why  she  behaved  in  such  an  extremely  foolish  man- 
ner. To  this  she  replied,  "  Because  it  is  that  girl  that  causes  me  the 
nightmare.  Oh,  please  send  some  food."  Q.  Are  you  hungry?  A.  Yes; 
I  want  something  in  my  stomach,  I  want  some  one  to  kiss  me.  She  recog- 
nizes a  pencil  and  an  eyeglass  when  shown  to  her.  She  begins  to  cry  when 
shown  a  penknife,  but  cannot  assign  any  reason  for  this  emotional  dis- 
turbance. She  suddenly  shouted  out,  "  Keep  on  writing  down  things,  send 
some  things,  I  want  to  go  to  town.  This  is  me,  this  is  me."  Q.  What  is 
your  name?  A.  You  kiss  me,  you  kiss  me,  then  it  will  be  all  right.  You 
kiss  me,  you  kiss  me,  you  feed  that  child  on  the  right  food.  Q.  Whom  do 
you  want  to  kiss?  A.  I  do  not  know.  Did  you  bring  me  any  c-a-k.  Oh, 
don't  go,  mother. 

The  patient  frequently  makes  mistakes  concerning  the  identity  of 
persons.  Refers  to  one  patient  as  "  little  blind  boy."  Sometimes  calls  the 
nurse  mother,  at  other  times  Aunt  Betsy. 


DEMENTIA    PR.ECOX 


385 


This  grotesque  irrelevancy  has  more  recently  been  made 
the  subject  of  careful  study.12  On  account  of  the  fact  that 
this  symptom  is  not  infrequently  associated  with  verbigeration, 
mild  cataleptic  states,  negativism,  echopraxia,  and  echolalia, 
Nissl  affirms  that  in  the  large  majority  of  cases  it  is  diag- 
nostic of  dementia  praecox  rather  than  of  hysteria.  Quite  re- 
cently attention  has  been  called  to  another  symptom  that  may 
be  referred  to  causes  similar  to  those  upon  which  the  irrele- 
vancy of  speech  depends.  It  is  well  illustrated  in  the  manner  in 
which  patients  comply  with  the  request  to  shake  hands,  doing 
so  in  an  irresolute,  more  or  less  indifferent  manner,  as  if  the 
command  were  only  feebly  comprehended.  Frequently  during 
the  period  of  catatonic  excitement  there  are  verbigeration  and 
the  rhythmic  repetition  of  numbers,  syllables,  and  words  which 
are  indirectly  related  either  to  the  content  of  the  question  or 
to  the  sound  of  the  word.  According  to  some  authors,  the 
essential  characteristic  of  the  complexity  of  the  manifestations 
in  this  form  of  mental  disorder  is  the  evident  lack  of  corre- 
spondence between  the  motor  symptoms.13  This  statement, 
however,  needs  to  be  qualified.  The  movements  are  frequently 
characterized  by  an  absence  of  unity  of  purpose  and  of 
coordination  which  contrasts  strikingly  with  certain  phases 
of  the  mental  state  of  the  patient.  For  example,  patients 
not  infrequently  exhibit  stereotypies,  catatonic  rigidity,  inco- 
ordinated  and  involuntary  spasms,  while  the  mental  examina- 
tion shows  that  they  are  well  oriented  and  that  there  is  com- 
paratively little  disturbance  in  the  power  of  recollection.  But 
this  dissociation  between  the  mental  and  motor  disturbance  is 
apparent  rather  than  real.      A  careful  study  of  a  case  shows 

12  Racke :  Beitrag  zur  Kenntniss  des  hysterischen  Dammerzustandes. 
Ztschr.  f.  Psych.,  lviii,  S.  115.  Hysterischer  Stupor  bei  Strafgefangenen. 
Ibid.,  S.  408.  Nissl :  Hysterische  Symptome  bei  einfachen  Seelenstor- 
ungen.  Centralbl.  f.  Nervenheilk.  u.  Psych.,  Nr.  144,  S.  2.  Wesphal : 
Ueber  hysterische  Dammerzustande  und  das  Symrtom  des  Vorbeiredens. 
Neurol.   Centralb.,   1903,  Januar  1,  Nr.   1,  S.  7. 

13  Paul  Masoin :  Observations  sur  la  demence  precoce  et  la  catatonic 
Bull,  de  la  Societe  de  Medecine  Mentale,  Decembre,  1902,  No.  107,  p.  366. 

25 


386  PSYCHIATRY 

that  there  is  a  functional  inhibition  affecting  the  motor  as 
well  as  the  psychical  powers.  In  dementia  prsecox  the  cere- 
brum seems  to  have  lost  the  faculty  of  responding  coordi- 
nately  to  external  stimulation,  while  a  purposeless  inexplicable 
inhibition  dominates  all  the  cortical  functions  with  tyrannical 
.power.14 

Hebephrenic  Form. — This  division  includes  two  groups  of 
cases  of  which  the  first  represents  the  type  of  disease  originally 
described  by  Hecker.  Here  we  have  to  do  with  a  chronic 
slowly  progressive  form  of  dementia  with  few  evidences  of 
negativism,  stereotypy,  motor  excitement,  or  impulsivity.  The 
apathy  and  progressive  dementia  are  the  prominent  symptoms. 
For  these  cases  Weygandt  has  proposed  that  the  term  dementia 
simplex  or  heboidophrenia  (the  latter  originally  suggested  by 
Kahlbaum)  should  be  retained.  He  reserves  the  name  hebe- 
phrenia for  a  group  of  cases  which  exhibit  marked  emotional 
disturbances,  periods  of  excitement  and  of  depression,  fre- 
quently accompanied  by  active  hallucinations  and  illusions, 
while  a  terminal  dementia  is  common  to  both  forms.  The 
characteristic  catatonic  symptoms,  such  as  mannerisms,  cata- 
lepsy, negativism,  stupor,  and  marked  motor  disturbances,  do 
not  become  pronounced  features.  The  essential  difference  in 
symptomatology,  according  to  Weygandt,  between  dementia 
simplex  and  hebephrenia  lies  in  the  fact  that  the  former  runs  a 
more  chronic  course  than  does  the  latter  group.  Wernicke  15 
affirms  that  heboidophrenia  or  heboid  possesses  more  of  the 
characteristics  of  a  specific  psychosis  than  does  hebephrenia. 
Although  clinically  an  attempt  to  establish  distinctions  between 
the  two  groups  of  cases  may  possess  certain  advantages,  it  is 
impossible  to  draw  sharp  and  definite  lines  in  all  cases.  The 
tendency  to  adhere  to  too  rigid  a  classification  may  retard 

14  The  motor  symptoms  play  a  very  important  part  in  the  clinical  picture 
of  the  disease.  The  observations  of  Bernstein  are  of  great  interest  in  this 
connection.  He  has  called  particular  attention  to  the  increase  in  the 
mechanical  irritability  of  the  muscles  and  the  formation  of  the  so-called 
idiomuscular  swelling  or  tumor.  (A.  Bernstein:  Ueber  die  klinische  Be- 
deutung  der  Muskelwulst  bei  Geisteskranken   (Russisch),  Moskau,  1900.) 

15  Grundriss  der  Psychiatrie,  1900,  S.  518. 


PLATE   IX 


DEMENTIA    PRECOX  387 

progress  by  emphasizing  differences  which  are  apparent  rather 
than  real ;  and  for  this  reason  at  the  present  it  is  inadvisable  to 
subdivide  this  group  of  cases. 

The  onset  in  this  form  of  the  disease  is  not  essentially 
different  from  that  already  described  as  characteristic  of  all 
forms  of  dementia  prsecox.  As  a  rule,  there  is  less  probability 
of  the  onset  being  acute  than  in  the  catatonic  cases.  If  a  care- 
ful history  is  obtained  it  is  generally  possible  to  show  that  the 
patients  for  years  prior  to  the  onset  of  the  more  definite  symp- 
toms of  alienation  have  exhibited  eccentricities  of  character. 
They  are  said  by  their  parents  to  be  seclusive,  to  shun  other 
children,  to  be  jealous,  over-particular  in  matters  of  dress,  and 
generally  hypercritical.  Up  to  a  certain  period,  generally  about 
the  time  of  puberty,  these  patients  may  develop  rapidly  intel- 
lectually, but  show  marked  capriciousness  and  general  emo- 
tional instability.  They  may  be  very  proficient  in  certain  sub- 
jects but  exceedingly  deficient  in  others.  Their  psychical  as 
well  as  their  physical  resistance  is  frequently  lowered.  As  a 
rule,  the  patients  are  described  by  those  who  have  known  them 
as  always  having  been  pale,  thin,  and  nervous  children.  The 
emotional  disturbances  are  characterized  by  sudden  and  ex- 
plosive outbursts  of  temper.  Not  infrequently  the  children 
who  later  become  hebephrenics  are  said  by  their  parents  or 
friends  to  have  been  even  in  early  life  at  times  over-pious  or 
excessively  conscientious.  At  times  they  are  given  to  brooding 
long  upon  subjects  which  generally  do  not  interest  children  of 
their  age.  When  the  period  of  puberty  approaches  these  indi- 
vidual idiosyncrasies  become  more  marked ;  the  patients  grow 
more  seclusive,  more  irritable,  and  markedly  emotional.  The 
eccentricities  of  character  begin  to  crystallize.  It  is  noted  by 
their  friends  that  they  rapidly  become  singularly  unconven- 
tional and  are  looked  upon  as  "  queer  fish."  When  perchance 
an  acute  infectious  disease,  such  as  scarlet  fever  or  influenza, 
intervenes,  or  they  suffer  some  injury  or  some  psychical  shock, 
they  convalesce  but  slowly  from  the  effects.  The  eccentricities 
of  character  now  become  exaggerated  and  the  emotional  apathy 
becomes  a  prominent  symptom,  taking  the  place  of  the  exces- 


388  PSYCHIATRY 

sive  enthusiasm,  transports  of  love,  and  foolish  infatuations  that 
have  occurred  during  the  earlier  stages.  The  memory  may  or 
may  not  be  greatly  impaired.  Vague  suspiciousness  develops. 
The  patient  becomes  self-centred,  gives  expression  to  indefinite 
fears,  is  distrustful  of  the  members  of  his  immediate  family. 
If  transitory  emotional  storms  develop,  it  is  noticed  that  the 
depth  of  feeling  is  not  commensurate  with  the  display.  This  is 
a  factor  of  great  importance.  Even  during  the  period  of  great- 
est storm  and  stress  evidences  of  this  apathy  may  be  detected. 
At  times  the  sense  of  well-being  is  apparently  intensified.  The 
patient  smiles  in  a  foolish  way,  says  that  he  never  felt  better, 
is  perfectly  satisfied  with  himself  and  the  world  in  general.  This 
state  of  complacency  is  not  persistent  and  differs  essentially  in 
this  respect  from  the  euphoria  of  paresis  and  other  conditions. 
When  the  disease  has  developed  the  disturbances  in  associative 
thinking  are  generally  marked.  Some  patients  rarely  take  the 
initiative  in  conversation,  while  in  others  there  may  be  a  typical 
disorganized  ataxic  expression  of  ideas  with  considerable 
speech  compulsion,  differing  essentially,  however,  from  that 
seen  in  the  maniacal  states.  The  complaints  made  by  the  pa- 
tients are  frequently  numerous  and  varied.  They  affirm  that 
something  is  queer  in  their  heads,  deplore  their  state  of  mental 
depression,  complain  of  insomnia,  of  disturbances  in  the  various 
organic  sensations,  that  they  are  subject  to  paresthesias  or 
neuralgias.  But  even  these  lamentations  are  devoid  of  emo- 
tional feeling.  In  the  milder  cases  the  hallucinations  and 
delusions  are  lacking  in  vividness  and  sensory  plainness.  They 
are  sometimes  referred  to  as  simple  light  or  color  sensations 
or  indefinite  sounds.  At  other  times  the  patients  affirm  that 
they  see  grotesque  and  bizarre  figures  or  hear  voices.  In  a 
comparatively  large  number  of  cases  these  disturbances  of  sen- 
sation seldom  reach  any  degree  of  severity. 

There  is  marked  disturbance  in  the  volitional  acts.  The 
patients  lounge  about  the  house  or  the  wards.  The  facial  ex- 
pression is  apathetic.  When  asked  why  they  do  not  occupy 
themselves,  they  reply  that  they  are  unable  to  do  so  or  refuse 
to  assign  any  reason.     At  times  they  sit  motionless  for  hours, 


DEMENTIA    PRECOX  389 

taking  little  interest  in  their  surroundings.  The  dull  expression 
of  the  face  may  occasionally  be  broken  by  the  sudden  inexplica- 
ble appearance  of  a  silly  smile  which  flits  across  the  countenance 
and  rapidly  vanishes.  The  changes  in  expression  are  purely 
impulsive.  The  orientation  in  the  milder  cases  is  fairly  well 
preserved.  Not  infrequently  in  testing  the  memory  it  is  ob- 
served that  many  patients  give  correct  answers  to  a  number  of 
questions  and  then  suddenly  the  replies  become  irrelevant, 
farcical,  and  puerile.  The  breaks  in  memory  are  frequently 
startling.     The  patients  remember  coming  to  the  hospital,  give 


JLc~       i* 


C  G.C.         S^n^  j 


This  is  a  facsimile  of  the  handwriting  of  a  case  of  dementia  praecox  (terminal  stage). 
The  patient  was  asked  to  give  a  short  resume  of  a  monograph  he  had  once  written  upon  a 
certain  tribe  of  Indians.  The  request  had  to  be  constantly  repeated  by  the  examiner,  as  the 
patient,  after  writing  one  or  two  words,  would  suddenly  break  off  and  attempt  to  leave  the 
room. 

the  year  correctly,  the  day  of  the  week  and  month,  and  then 
fail  utterly  to  recall  their  own  names.  The  grotesque  irrele- 
vancy in  their  replies,  to  which  allusion  has  already  been  made, 
is  not  infrequent  in  this  form  of  the  disease. 

As  the  dementia  progresses  many  of  these  patients  exhibit 
occasional  signs  of  negativism,  stereotypy,  and  automatism,  but 
there  are  cases  in  which  these  symptoms  are  more  or  less  marked 
from  the  beginning  to  the  end  of  the  disease.  In  the  latter  the 
diagnosis  is  frequently  very  difficult  and  can  only  be  made  after 


390 


PSYCHIATRY 


the  patient  has  been  under  observation  for  a  considerable  period 
of  time.  This  simple  dementing  form  is  of  great  practical  and 
forensic  importance.16  The  onset  is  very  insidious.  The  defects 
in  intelligence  and  anomalies  of  emotions  may  be  very  slight. 
The  specific  symptoms  do  not  develop.  The  progress  is  exceed- 
ingly slow  and  the  course  may  be  masked  by  long  periods  during 
which  the  patient's  condition  remains  unchanged.  In  the  lower 
classes  of  society  these  patients  are  frequently  found  among 
the  tramps  and  vagabonds.  On  superficial  examination  it  is 
impossible  to  demonstrate  any  marked  mental  defect.  Thought 
that  does  not  require  much  concentration  or  protracted  effort  is 
unimpaired.  If,  however,  the  patient's  attention  is  long  riveted 
upon  one  theme  spasmodic  irrelevancy  and  a  tendency  to  jump 
from  one  topic  to  another  may  become  apparent.  Written  as 
well  as  spoken  language  may  be  formally  correct.  Orientation 
and  the  power  of  picking  up  and  retaining  new  impressions  is 
fairly  well  preserved.  Ethical  defects  sooner  or  later  become 
obvious.  These  are  apt  to  be  noticeable  first  about  the  time 
of  adolescence.  Individuals  resent  discipline,  become  antisocial, 
addicted  to  drugs,  particularly  to  alcohol,  but  do  not  give  such 
marked  evidences  of  sexual  excesses  or  irregularities  as  are 
met  with  in  the  other  forms  of  the  disease.  The  same  is  true  in 
regard  to  the  commission  of  actual  crimes.  These  are  common 
in  the  severer  types  of  the  disease  if  the  patient's  liberty  is  not 
restricted,  but  vagabondage  and  the  commission  of  minor 
offences  characterize  many  cases  of  this  slow  dementing  type. 
The  intolerance  for  alcohol  is  marked.  This  symptom  alone 
may  be  the  means  of  bringing  the  patients  to  hospitals  for 
observation  and  treatment.  As  the  disease  progresses  the  in- 
dividuals may  be  thought  to  be  merely  very  eccentric  or  ethically 
deficient,  but  the  true  character  of  the  disorder  is  seldom  recog- 
nized. Very  gradually,  it  may  be  after  the  lapse  of  years  and 
without  the  occurrence  of  acute  exacerbations,  the  signs  of 
dementia  prsecox  appear. 


18  Diem,    Otto :     Die    einfach    demente    Form   der    Dementia    Pracox. 
Archiv  f.  Psych,  u.  Nervenk.,  Bd.  xxxvii,  Heft  i. 


DEMENTIA    PRECOX 


391 


Catatonic  Form. — The  most  prominent  symptoms  in  this 
form  of  the  disease  are  cyclic  alternating  periods  of  depression, 
mania  with  characteristic  motor  disturbances,  stupor,  and  con- 
fusion. Their  relative  prominence  in  individual  cases  varies 
considerably.  In  some  instances  the  depression  and  stupor  are 
more  marked,  in  others  the  excitement  and  motor  symptoms. 
The  affirmation  made  by  some  observers  to  the  effect  that  char- 
acteristic motor  symptoms  may  be  entirely  absent  during  the 
whole  course  of  the  disease  is  not  confirmed  by  the  clinical  evi- 
dence. On  the  contrary,  careful  routine  examinations  made  at 
different  stages  in  the  disease  show  that  they  are  always  present. 
Patients  whose  symptoms  are  so  obscure  that  it  is  at  first  im- 
possible to  recognize  them  as  catatonic  are  frequently  admitted 
to  hospitals.  More  frequently  even  than  in  the  other  forms  of 
the  disease  a  history  may  be  obtained  from  the  relatives  or 
friends  which  at  first  suggests  the  possibility  of  an  acute  onset. 
We  find  that  after  an  acute  attack  of  illness  the  patient  had 
convalesced  but  slowly  and  during  this  period,  while  subjected 
to' some  unexpected  physical  or  mental  strain,  the  symptoms  of 
catatonia  developed.  As  a  rule,  the  signs  of  mental  depression 
are  the  first  to  appear.  This  type  of  melancholy  is  often  difficult 
to  differentiate  from  that  occurring  in  manic-depressive  insan- 
ity. At  times  the  patients  pass  from  depression  into  a  period  of 
mutism  which  may  persist  for  days,  weeks,  or  even  months. 
Generally  at  some  time  during  this  interval  there  are  well- 
marked  symptoms  of  negativism.  If  the  patient  is  in  bed, 
immediately  on  the  approach  of  the  physician  the  bedclothes 
are  drawn  over  the  head,  the  slightest  touch  is  resented,  and 
every  attempt  is  made  to  get  beyond  the  reach  as  well  as  out  of 
the  sight  of  the  examiner.  Patients  who  are  so  afflicted  and  are 
walking  about  the  wards  run  to  a  far  corner,  hide  behind  the 
door,  in  the  closets,  under  the  bed.  If  restrained,  they  often 
resist  actively.  If  the  head  is  held,  they  refuse  to  look  at  the 
physician.  To  the  casual  observer  the  negativistic  symptoms 
seem  to  develop  without  rhyme  or  reason.  All  forms  of  ex- 
ternal stimuli  seem  to  arouse  an  aimless,  capricious,  silly  resist- 
iveness.     Frequently  such  patients  struggle  violently,  without 


392 


PSYCHIATRY 


uttering  a  sound,  to  get  away  from  the  nurse  or  attendant  or 
may  burst  out  into  a  silly  laugh.  Sometimes  they  become  very 
angry,  but  this  emotional  display  generally  indicates  the  pres- 
ence of  some  delusion.  The  negativism  may  persist  for  weeks 
at  a  time.  During  this  period  patients  frequently  refuse  all 
nourishment,  so  that  forced  feeding  has  to  be  resorted  to.  There 
may  also  be  a  voluntary  retention  of  the  urine  and  faeces.  In 
addition  to  negativism  marked  stereotypy  of  word  and  action 
may  become  a  prominent  feature.  The  patients  will  stand  for 
hours  in  one  spot.  If  the  condition  known  as  cerea  Hexibilitas  is 
present  they  maintain  for  long  intervals  of  time  any  attitude  in 
which  they  are  placed.  At  times  catatonics  seem  to  have  a  very 
restricted  capacity  for  holding  idiomotor  images  in  conscious- 
ness. If  the  arm  is  elevated  and  placed  in  an  uncomfortable 
position  there  is  no  tendency  to  allow  it  to  fall  either  in  response 
to  various  forms  of  pain  stimuli  or  when  the  other  arm  or  a  leg 
is  put  in  an  equally  uncomfortable  position ;  but  the  moment  the 
attention  is  directed  to  carrying  out  some  voluntary  act,  such  as 
protruding  the  tongue,  closing  one  eye  ,or  flexing  and  extending 
the  fingers,  the  arm  which  has  been  elevated  slowly  drops  to  the 
side.  During  the  earlier  stages  of  this  depression,  which  is  more 
apparent  than  real,  a  condition  suggesting  psychomotor  retar- 
dation develops.  The  more  carefully  the  patients  are  stud- 
ied the  less  obvious  becomes  the  actual  change  in  the  emotional 
tone.  What  was  at  first  taken  for  depression  is  found  in  reality 
to  be  apathy.  If  the  patient  during  the  period  of  depression  tells 
us  of  certain  hypochondriacal  feelings,  a  marked  incongruity 
between  the  objective  expression  and  the  emotional  tone  can 
be  detected.  In  the  very  earliest  stages  this  apathy  is  evidenced 
by  a  certain  degree  of  listlessness,  lack  of  interest  in  the  sur- 
roundings, and  an  evident  embarrassment  which  is  increased 
when  the  patient  is  conscious  of  being  watched.  This  state  is 
evanescent  in  character.  During  this  period  patients  not  infre- 
quently are  very  impulsive  and  may  show  marked  suicidal  ten- 
dencies. Acts  are  not  performed  with  any  degree  of  deliberation 
and  seem  to  be  the  result  of  pure  impulse.  When  the  depression 
deepens  a  catatonic  stupor  may  intervene.     To  all  outward  ap- 


PLATE   X 


Cerea  flexibilitas  in  a  slowly  developing  case  of  dementia  praecox.  When  this  patient  first 
came  under  observation  at  the  Johns  Hopkins  Dispensary  there  was  only  a  very  mild  degree 
of  dementia  present. 


DEMENTIA    PRECOX  393 

pearances  the  patient  leads  a  purely  vegetative  existence;  the 
face  is  apathetic,  expressionless ;  extra-organic  stimuli,  as  a  rule, 
produce  little  or  no  evidence  of  reaction.  The  muscular  rigidity 
on  passive  movement  is  usually  well  marked.  In  some  instances 
all  the  muscles  of  the  trunk  and  extremities  are  involved,  while 
in  others  only  certain  groups  seem  to  be  affected.  The  rigidity 
may  be  more  or  less  limited  to  the  movements  of  flexion  or 
extension ;  at  times  pronation  and  supination  are  also  involved. 
Occasionally  the  face  shows  involvement,  and  in  exceptional 
instances  the  muscles  of  mastication  may  become  so  rigid  that 
the  jaws  are  tightly  closed.  All  passive  movements,  as  a  rule, 
awaken  antagonism  in  the  opposing  muscles.  In  the  catatonic 
contraction  there  is  a  marked  hypertonia  of  the  muscles.  This 
may  frequently  be  so  intense  that  it  is  impossible  to  alter  the 
position  of  the  limb  in  a  catatonic  without  using  great  force. 
The  antagonistic  action  of  muscles  may  be  quickly  recognized 
when  the  examiner  attempts  to  flex  or  extend  passively  the  limb 
of  the  patient.  Observers  differ  essentially  in  regard  to  the 
specific  importance  of  the  symptom  known  as  cerea  flexibilitas. 
Some  clinicians  affirm  that  this  condition  may  frequently  be 
met  with  in  the  manic  stupor  of  manic-depressive  insanity  as 
well  as  in  other  psychoses.  Pain  stimuli  are  usually  not  fol- 
lowed by  an  apparent  reaction.  The  skin  may  be  pricked  with 
a  needle  or  stimulated  with  a  strong  galvanic  or  faradic  current 
without  any  evidences  of  sensation.  The  conduction  of  the 
nerves  for  electrical  stimuli  has  been  investigated,  but  the  re- 
sults so  far  obtained  are  conflicting.  The  patient  makes  few, 
if  any,  movements.  Attempts  at  passive  movements  may  evoke 
considerable  rigidity.  A  patient  will  often  keep  his  hands  so 
tightly  flexed,  the  finger-tips  and  nails  pressing  deeply  into  the 
palms  of  the  hands,  that  it  is  necessary  to  forcibly  open  the 
hands  and  give  him  something  to  grip  upon,  in  order  to  prevent 
maceration  of  the  palms  of  the  hands  and  fingers.  Frequently 
the  eyes  are  kept  tightly  closed,  or  again  they  are  partly  or  wide 
open.  The  eyeballs  may  be  touched  without  any  evident  reac- 
tion. During  the  continuance  of  this  state  external  stimuli 
neither  increase  nor  diminish  the  rapidity  of  the  pulse  nor  the 


394  PSYCHIATRY 

rhythm  of  the  respiration.  But  in  spite  of  the  presence  of  these 
symptoms  the  psychical  functions  are  not  completely  inhibited. 
Days  or  weeks  afterwards  when  the  patient  has  emerged  from 
this  condition  it  is  found  that  events  that  have  occurred  during 
this  stuporous  state  are  sometimes  recalled  in  such  detail  as  to 
show  a  remarkable  degree  of  memory.  The  transition  from  this 
stage  may  be  gradual  or  in  some  instances  sudden.  Occasion- 
ally a  patient  who  has  been  in  a  deep  stupor  for  weeks  in  a  few 
hours  becomes  completely  changed,  is  able  to  answer  questions, 
to  walk  about  the  ward,  and  give  a  rational  account  of  every- 
thing that  is  transpiring.  It  may  be  weeks,  however,  before 
the  transformation  is  complete.  In  some  cases  the  period  of 
stupor  is  not  well  marked  and  the  depression  may  be  followed 
immediately  by  a  maniacal  condition.  During  this  time  the 
acts  of  the  patient  may  suggest  the  frenzied  state  of  epileptics. 
Every  stimulus  is  unduly  magnified  and  there  seems  to  be  no 
power  of  inhibition  present.  If  given  their  liberty,  the  patients 
rush  wildly  about  the  wards,  assaulting  other  patients,  nurses, 
or  whoever  happens  to  come  in  their  way,  throwing  themselves 
against  the  wrall,  on  the  floor,  striking  and  breaking  pieces  of 
furniture,  etc. 

Hallucinations  and  delusions  may  be  associated  with  the 
impulses.  The  patients  see  fantastic  figures,  devils,  spirits.  As 
a  rule,  they  affirm  that  these  phantoms  are  of  a  hostile  character 
and  are  trying  to  injure  or  kill  them.  At  times  these  delusions 
have  a  sexual  basis.  The  patients  affirm  that  evil  spirits  are 
trying  to  outrage  them  or  that  they  are  forced  to  do  unclean 
things  against  their  will.  When  interrogated  as  to  their  physi- 
cal condition  a  whole  chain  of  delusions  suddenly  springs  into 
the  foreground  of  consciousness.  Any  and  all  questions  ac- 
tively initiate  and  arouse  anger.  The  physician  is  peremptorily 
told  to  get  out  of  the  room,  and  if  the  request  is  not  at  once 
complied  with  summary  vengeance  is  threatened.  On  being 
left  to  himself  the  patient  may  at  once  become  quiet,  sitting 
down  and  relapsing  into  an  apathetic  state,  but  on  the  approach 
of  any  one  he  suddenly  springs  up  again  and  becomes  aggres- 
sively offensive.     The  excited  catatonic  patient  is  a  source  of 


DEMENTIA    PRECOX  395 

great  danger  to  himself  as  well  as  those  about  him.  The  change 
from  the  state  of  apparent  apathy  to  one  of  the  wildest  excite- 
ment is  instantaneous.  The  duration  of  these  periods  of  excite- 
ment, as  well  as  of  those  of  depression  or  stupor,  vary  greatly 
in  duration.  The  paroxysms  are  characterized  by  greater  im- 
pulsivity,  more  explosive  emotional  gusts,  in  which  the  acts  are 
more  unpremeditated  and  more  inexplicable  than  those  occur- 
ring during  the  motor  excitement  in  the  manic-depressive 
insanity.  The  actions  as  well  as  the  speech  of  the  excited 
catatonic  are  either  monotonous  and  iterative  or  are  startling, 
inapposite,  and  bear  no  relation  to  the  incident  stimuli.  The 
tendency  to  harp  on  one  theme,  the  inane  jargon  that  is  appar- 
ently not  conditioned,  nor  deflected  by  extra-organic  stimuli,  is 
in  marked  contrast  to  the  typical  flightiness  of  the  maniacal  pa- 
tient. The  expressions  used  by  catatonics  are  sometimes  only 
senseless  syllables,  stereotyped  expressions  repeated,  it  may  be, 
for  hours  at  a  time.  If  an  attempt  is  made  to  deflect  or  to 
stop  these  babblings,  the  patients  only  shout  the  louder.  During 
the  excitement  catatonics  often  refuse  food.  If  unrestrained, 
they  dash  dishes  on  the  floor,  fling  them  across  the  ward,  strug- 
gle violently  while  being  fed,  or  tear  their  clothes  to  pieces. 
Certain  individuals  show  only  a  limited  motor  excitability, 
while  in  others  there  is  a  general  restlessness ;  they  skip,  hop, 
run,  jump,  and  keep  up  an  incessant  motion,  not  infrequently 
carrying  on  these  antics  with  a  silly  smile  on  their  faces.  They 
bump  heedlessly  into  the  furniture,  shove  any  one  out  of  the 
way  who  happens  to  be  near,  if  they  do  not  actually  strike  or 
kick  him.  Although  considerable  force  may  be  coupled  with 
these  actions,  the  patients  often  are  not  deliberately  aggressive 
and  will  not  try  to  injure  any  one  unless  interfered  with. 

Psycho-ancesthesias  are  not  uncommon.  Some  patients 
fling  themselves  about,  caring  little  how  or  where  they  strike, 
and  frequently  inflict  severe  injuries  upon  themselves.  Even 
these  coarse,  unpremeditated  movements,  as  a  rule,  show  some 
evidence  of  stereotypy.  There  is  no  marked  incoordination,  but 
the  patients  are  decidedly  clumsy,  and  any  appearance  of  grace 
and  ease  is  absent. 


396  PSYCHIATRY 

This  form  of  the  disease  varies  within  wide  limits.  The 
degrees  of  intensity  and  duration  of  individual  symptoms  can 
not  be  foretold.  The  stuporous  condition  may  last  for  months 
and  the  relative  prominence  of  the  mannerisms,  tics,  nega- 
tivism, command  automatism,  is  different  in  each  case  that 
comes  under  observation.  The  catatonic  excitement  may  show 
occasional  remissions  or  exacerbations,  or  may  continue  un- 
changed for  months,  or  in  extreme  cases  for  even  two  or  three 
years. 

Paranoiic  Form. — This  type  of  the  disease  is  represented 
in  part  by  cases  in  which  catatonic  symptoms  first  appear  and 
are  followed  later  by  the  development  of  fixed  systematized 
insane  ideas.  These  cases  end,  as  do  the  other  forms,  in  a 
terminal  dementia.  Many  of  them,  until  recently,  were  gen- 
erally classified  under  paranoia.  On  account  of  the  chronic  and 
frequently  stable  character  of  the  paranoiic  symptoms  it  is 
often  impossible  to  make  a  diagnosis  unless  a  complete  history 
of  the  case  is  obtained.  In  the  early  stages  periods  of  depres- 
sion, of  excitement,  of  stupor,  and  the  characteristic  catatonic 
motor  disturbances — rigidity,  negativism,  stereotypy,  and  ver- 
bigeration— occur.  Many  observers  in  discussing  the  subject  of 
paranoia  attempt  to  distinguish  between  chronic  simple  par- 
anoia and  the  hallucinatory  form.  If  these  paranoiic  states  are 
carefully  studied,  symptoms  characteristic  of  dementia  praecox 
can  frequently  be  noted  at  some  time  during  their  course.  Ac- 
cording to  Weygandt17  this  group  of  cases,  in  which  in  the 
earlier  stages  hallucinations  are  a  prominent  symptom  followed 
later  by  stable  organized  insane  ideas,  represents  a  definite 
clinical  type  of  the  disease.  The  hallucinations  are  frequently 
strange,  fantastic,  and  seem  to  exert  a  remarkable  influence 
over  all  volitional  acts.  One  patient  under  observation  in  the 
hospital  refused  to  work,  as  he  affirmed  that  the  birds  in  the 
trees  talked  to  him  and  he  was  obliged  to  listen  to  what  they 
said.  He  also  told  us  that  at  times  voices  repeated  things  to 
him,  generally  of  a  pleasant  character.     Frequently  hallucina- 

17  Weygandt :    Op.  cit. 


DEMENTIA    PRECOX 


397 


tions  and  the  insane  ideas  are  combined  in  such  a  way  as  to 
give  the  picture  of  a  well-ordered  systematized  persecutory 
paranoia.  The  patients  affirm  that  they  are  being  chased  about 
by  devils,  receive  electric  shocks,  are  being  communicated  with 
by  spirits ;  the  room  is  full  of  invisible  forms  who  are  con- 
stantly harassing  thjem.  These  ideas  may  persist  for  years, 
gradually  becoming  more  foolish  and  absurd,  and  the  disor- 
ganization of  associated  memory  becomes  more  and  more 
marked.  Not  infrequently  hypochondriacal  symptoms  are 
present.  When  asked  why  they  do  not  work,  the  patients  affirm 
that  they  are  unable  to  do  so,  that  the  heart  has  been  displaced, 
that  certain  organs  are  wanting,  that  they  lack  the  power  to 
concentrate  their  attention.  Sometimes  they  express  a  willing- 
ness to  work,  but  contend  that  they  are  prevented  from  doing 
so  by  the  action  of  spirits,  devils,  fiends.  One  patient  for  months 
at  a  time  complained  of  stomach  trouble.  He  would  stand  for 
hours  kneading  his  abdomen  and  trying  to  belch  up  wind. 
Occasionally  impulsive  acts  appear,  at  other  times  mannerisms ; 
again  the  speech  suggests  the  word  hotch-potch  or  verbigeration, 
or  the  patients  may  show  plainly  command  automatism.  The 
auditory  are  more  common  than  visual  hallucinations,  although 
the  latter  sometimes  occur.  Not  infrequently  olfactory  hallu- 
cinations are  present.  Patients  affirm  that  dead  animals  have 
purposely  been  left  outside  their  door  and  that  the  unpleasant 
odors  are  a  continual  source  of  annoyance. 

Another  group  of  cases  are  those  described  by  Kraepelin 
under  the  term  dementia  paranoides.  Here  the  hallucinations 
are  less  in  evidence,  but  the  insane  ideas  of  persecution  and 
megalomania  become  more  prominent.  At  times,  early  in  the 
disease,  the  hallucinations  have  great  sensory  vividness,  but  this 
is  soon  lost  and  instead  the  chronic  systematized  delusions  de- 
ficient in  objective  plainness  occur.  The  delusions  are  protean 
in  character.  Sooner  or  later  during  the  course  of  the  disorder 
symptoms  described  as  characteristic  of  dementia  prsecox  are 
sure  to  appear.  At  times  patients  are  so  disputatious  and 
querulous  as  to  justify  their  classification  among  the  cases  of 
so-called  litigious  insanity.     Again,  it  may  be  very  difficult  to 


398  PSYCHIATRY 

differentiate  them  from  the  true  paranoiics,  and  this  can  only 
be  done  when  it  is  possible  to  obtain  from  competent  observers 
a  full  history  of  the  case.  Instances  are  reported  in  which  pa- 
tients have  been  so  specious  and  plausible  in  the  statement  of 
their  supposed  grounds  for  controversy  and  wrangling  that  the 
affairs  have  been  carried  to  court.  In  the  more  pronounced 
cases  there  is  marked  dissociation  of  thought  as  well  as  impair- 
ment of  volition  and  emotional  apathy.  The  stories  told  by 
the  precocious  dements  are,  as  a  rule,  illogical  and  lack  the  con- 
tinuity of  those  of  the  paranoiic.  The  patients  sometimes  give 
an  account  of  the  manner  in  which  they  have  been  ill-treated  by 
their  friends.  Up  to  a  certain  point  the  tale  is  logical  and  to 
all  intents  and  purposes  truthful;  then  unexpectedly  some 
unseen  agency  is  introduced  without  rhyme  or  reason,  and  they 
confess  that  certain  acts  committed  have  been  due  to  the  ad- 
monitions of  spirits  or  of  departed  souls.  Occasionally  the 
character  of  the  megalomania  is  pathognomonic  for  this  type 
of  the  disease.  The  same  fantastic  unreal  elements  enter  into 
its  composition.  The  patients  affirm  that  they  are  in  league 
with  spirits,  receive  information  from  them;  that  they  have 
the  power  of  second  sight;  have  communication  with  other 
worlds ;  that  they  are  princes  or  princesses  of  the  Pole  Star. 
While  affirming  this  in  one  breath  they  complain  of  their  help- 
lessness in  another ;  that  they  are  powerless  and  unable  to  help 
themselves. 

Associated  with  the  megalomania  there  is  frequently  a 
slight  emotional  depression.  The  hypochondriacal  complaints 
are  characterized  by  an  apparent  lack  of  emotional  feeling.  In 
some  instances,  as  has  already  been  said,  the  continuity  and 
logical  character  of  the  insane  ideas  are  well  maintained,  while 
in  others  the  aid  of  mysticism,  clairvoyance,  spiritualism,  and 
Christian  Science  is  invoked  to  explain  anomalies  of  thought 
and  action.  In  these  latter  cases  the  ideas,  as  a  rule,  are  more 
incoherent,  and  the  strangest,  weirdest,  and  most  extravagant 
forms  of  speech  are  employed.  These  patients  are  excessively 
capricious,  full  of  fads,  crotchety,  inconsistent,  and  erratic  to 
an  extreme  degree.    Their  conduct  is  in  a  measure  conditioned 


DEMENTIA    PRECOX 


399 


by  the  insane  ideas.  Impulsivity  is  marked  at  times,  at  others 
there  are  frequent  mannerisms  and  displays  of  arrogant  ego- 
tism, ostentatiousness,  and  priggishness.  The  stereotypies  vary 
greatly  in  character.  Some  individuals  never  leave  the  ward 
without  walking  along  a  certain  line  on  the  carpet.  Others 
sit  in  one  place,  half  automatically  play  games  of  cards — soli- 
taire— for  hours,  shuffling  the  cards  in  the  same  stereotyped 
way,  playing  game  after  game  correctly  but  in  a  mechanical 
manner,  yet  apparently  taking  little  or  no  interest  in  what  they 
are  doing.  Voluntary  conversation  is  sometimes  limited,  at 
other  times  there  is  a  tendency  to  be  garrulous.  The  inability 
to  divert  and  direct  the  patient's  train  of  thought  is  singularly 
noticeable.  These  individuals  become  irresponsive  to  external 
stimuli  although  the  primary  sensations  are  exceedingly  well 
preserved. 

Dementia  Paranoides. — Admitted  to  hospital  December  15,  1896. 
Male,  aged  34,  single. 

Family  History. — Mother  nervous.     Rest  of  family  history  negative. 

Personal  History. — Early  history  of  patient  somewhat  indefinite.  Al- 
though said  to  have  been  unusually  bright  at  school  and  college  and  always 
ranking  well  in  his  favorite  studies,  he  showed  no  aptitude  for  others. 
Was  a  close  and  hard-working  student.  Manner  diffident,  disposition 
retiring.  While  abroad  in  1892  he  broke  down  from  overwork  and  was  in 
a  hospital  for  some  time  undergoing  treatment.  Was  brought  home  in 
1894.  While  living  at  home  he  worked  for  some  time  in  a  desultory  way, 
was  very  reticent,  secluded  himself  from  others,  was  inclined  to  take 
violent  dislikes  towards  members  of  his  family,  but  was  never  violent. 
Became  suspicious  of  his  friends  without  cause  and  refused  to  be  con- 
trolled. Came  to  the  hospital  willingly  when  told  he  had  been  committed. 
Upon  admission  he  was  quiet  and  reticent,  answered  questions  in  mono- 
syllables, but  quite  coherently,  and  said  he  would  remain  quietly  here. 

Physical  Condition. — Spare  in  flesh.  Movements  nervous  and  awk- 
ward, head  ill-shapen,  forehead  flat.  Complained  of  dyspepsia  of  intestinal 
type.  Remained  in  hospital  until  January  10,  1896,  when  he  was  discharged 
and  left  for  home.  During  stay  at  home  he  was  diffident  and  seclusive,  ate 
and  slept  fairly  well,  improved  somewhat  in  weight  and  strength.  Several 
attempts  were  made  to  employ  him,  but  he  showed  no  power  of  attention. 

Readmitted  December  15,  1896.  Condition  about  the  same  as  when 
in  hospital,  except  he  had  gained  somewhat  in  flesh  and  strength.  During 
1897  his  general  condition  remained  the  same.  Returned  to  the  hospital  and 
was  allowed  to  go  home  for  a  day  or  two  at  a  time.  Expressed  the  delusion 
that  a  battery  was  being  worked  on  him.    Once  he  left  the  dinner-table  very 


4oo  PSYCHIATRY 

suddenly,  tipping  over  his  chair  in  doing  so.  When  asked  why  he  had  done 
so,  he  said  that  a  galvanic  battery  had  been  applied  to  him  and  that  the  doc- 
tors knew  all  about  it.  Occasionally  was  somewhat  agitated  and  markedly 
discontented  and  often  asked  to  be  allowed  to  go  home.  At  other  times 
would  sit  for  long  periods  staring  vacantly  into  space.  Ate  and  slept  well. 
Would  read  newspapers  and  medical  journals  to  some  extent,  but  gradu- 
ally lost  interest.  At  one  time  he  helped  with  the  urinary  analyses  in  the 
laboratory,  but  was  erratic  in  the  work  and  not  to  be  depended  upon. 
During  1898  kept  a  great  deal  to  his  room,  came  late  to  meals,  was  easily 
disturbed  by  the  noises  in  the  adjoining  room,  moved  away  from  people 
because  he  thought  "  they  wish  to  say  things  they  do  not  want  me  to  hear." 
Swore  considerably,  sometimes  at  the  doctor.  Always  late  in  going  out  for 
exercise,  irritable,  seldom  smoked.  He  thought  the  nurses  were  trained  to 
keep  food  away  from  him.  Tiptoed  around  in  a  suspicious  manner ;  thought 
he  heard  noises  coming  from  the  register  and  these  frightened  him.  Com- 
plained of  chirping  of  birds  and  kept  his  window  closed.  Was  apt  to  wan- 
der from  the  walking-party  "  to  look  for  bones  of  dead  animals."  One 
day  he  suddenly  became  impulsive,  and  without  provocation  threw  a  cup 
at  a  nurse.  Very  slow  in  dressing.  Would  pick  up  his  collar  and  shirt 
and  blow  them  off  as  if  trying  to  get  them  clean. 

In  1901  he  exhibited  the  following  peculiarities :  Excessive  washing  of 
hands.  Would  bathe  from  one  to  two  hours.  His  manner  and  position 
were  decidedly  awkward.  Would  not  look  at  observer  straight  in  the  eye, 
simply  glanced  at  him  and  then  immediately  looked  away  as  if  embarrassed. 
Replied  to  questions  put  to  him  in  as  few  words  as  possible.  Did  not  volun- 
teer any  information.  Objected  to  examination  on  the  grounds  that  this 
procedure,  as  conducted  by  the  doctors,  was  unfair  and  that  the  information 
thus  obtained  might  be  used  to  identify  him  if  he  escaped.  He  said  the 
doctors  maligned  him  and  made  fun  of  his  gait  and  other  peculiarities. 
Very  suspicious  and  thought  that  people  were  trying  to  injure  him  and 
accounted  in  this  way  for  his  confinement  in  the  institution. 

Physical  Examination. — No  defect  in  speech.  Thorax  shows  noth- 
ing remarkably  abnormal.  Reflexes  slightly  exaggerated.  Memory  for 
past  events  accurate  and  correct.  Mental  reactions  quick.  Patient  has  an 
exaggerated  sense  of  modesty.  Orientation  normal.  Has  a  number  of 
auditory  delusions. 

December,  1903.  The  mental  reduction  is  gradually  becoming  more 
pronounced. 

The  So-called  Lucid  Intervals  and  Terminal  Stage. — A 
great  many  of  the  cases  of  dementia  prsecox  end  in  a  specifically 
characteristic  dementia,  in  which  the  emotional  anomalies  and 
intellectual  impairment  give  color  to  the  clinical  picture.  The 
limitation  and  inhibition  of  volitional  acts  are  also  marked. 
Sense  perception,  as  a  rule,  is  singularly  well  preserved.  Man- 
nerisms, stereotypies  of  thought  and  act,  impulsivity,  negativ- 


DEMENTIA    PRECOX  401 

ism,  command  automatism,  stuporous  and  cataleptic  states,  may 
persist  during  the  dementia  and  recur  at  varying  intervals  with 
a  greater  or  lesser  degree  of  severity.  All  forms  of  the  disease 
may  end  in  the  severer  grades  of  dementia,  nor  are  there  any 
known  signs  by  which  in  any  given  case  the  degree  of  severity 
can  be  foretold.  In  a  general  way,  however,  it  may  be  said  that 
the  paranoiic  forms  are  less  liable  to  show  an  abatement  in  the 
intensity  of  the  symptoms  than  are  the  hebephrenic  or  catatonic 
types.  No  instances  on  record  can  be  adduced  to  prove  con- 
clusively that  there  is  ever  a  restitutio  ad  integrum  after  the 
disease  has  developed  far  enough  to  permit  an  accurate  diag- 
nosis to  be  made.18  In  the  lowest  classes  of  society  the  perma- 
nent defects  in  the  volitional,  emotional,  and  intellectual  spheres 
may  escape  notice  owing  to  failure  to  recognize  them  as  distinct 
from  mere  idiosyncrasies  the  result  of  the  low  social  status  of 
the  individual.  According  to  Kraepelin  8  per  cent,  of  the 
heboid  and  hebephrenic  and  13  per  cent,  of  the  catatonic  patients 
recover  sufficiently  to  resume  their  ordinary  occupations  at 
home.  It  is  always  possible,  however,  to  demonstrate  in  these 
individuals  residuary  psychical  defects.  Meyer,19  basing  his 
observation  on  the  study  of  46  cases  of  catatonia  ad- 
mitted to  the  Tubingen  clinic,  affirms  that  the  prognosis  is 
relatively  more  favorable  in  the  cases  where  the  onset  is  sudden 
and  the  stupor  an  early  symptom  than  it  is  when  the  disease 
begins  more  gradually  and  the  stereotypies  are  pronounced. 

This  phase  is  in  contrast  to  the  retained  intellectuality  in 
the  lucid  intervals  of  many,  but  not  all,  of  the  cases  of  manic- 
depressive  insanity.  The  periods  of  improvement  frequently 
recorded  during  an  attack  of  dementia  prsecox  may  be  inter- 
rupted at  any  time  by  an  acute  exacerbation  of  the  disease. 

The  physical  symptoms  of  dementia  praecox  are  multiform, 
but  individually  none  is  specifically  characteristic.  A  muddy 
complexion  is  frequently  noted  in  patients  in  whom  mental 

18  A  contrary  opinion  has  recently  been  entertained  by  Karl  Kahlbaum. 
Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  xii,  Juli,  1902,  Heft  I,  S.  58. 

18  Meyer,   E. :    Zur  prognostischen   Bedeutung  der  katatonischen   Er- 
scheinungen.     Munch,  med.  Wchnschr.,  1903,  Nr.  32. 

26 


402 


PSYCHIATRY 


depression  is  a  prominent  symptom  and  acne  vulgaris  is  quite 
common.  In  the  more  chronic  cases  the  sufferers  have  a 
peculiar  pasty  appearance,  the  features  not  infrequently  sug- 
gesting the  changes  which  occur  in  myxcedema.  Sometimes 
the  patients  look  younger  than  they  really  are,  but  this  ex- 
pression would  strike  the  careful  observer  as  not  due  to  the 
preservation  of  functions  seen  in  normal  individuals,  but  rather 
as  suggesting  the  juvenile  appearance  of  one  whose  mental 
development  has  lagged  behind.  In  one  patient  that  came 
under  observation  during  the  attack  of  depression  which  pre- 
ceded the  excitement  there  was  a  marked  acneiform  eruption 
limited  to  the  forehead.  This  was  associated  with  gastro- 
intestinal disturbances,  and  persisted  through  the  period  of 
depression,  but  passed  away  before  the  end  of  each  maniacal 
outbreak. 

Vasomotor  disturbances  are  common.  There  may  be 
marked  dermatographia.  The  skin  is  apt  to  be  dry  or  it  may 
have  a  greasy  appearance.  At  times  there  may  be  a  tremor  of 
.  the  tongue  and  extremities,  and  a  weakness  and  temporary 
spastic  condition  of  the  latter  have  been  described  in  some  cases. 
Not  uncommonly  there  is  a  marked  increase  in  the  mechanical 
irritability  of  the  muscles  supplied  by  the  facial  nerve.  Tapping 
over  this  region  elicits  a  short,  sharp,  quick  contraction,  and  this 
hyper-excitability  sometimes  involves  not  only  the  muscles 
directly  stimulated,  but  also  those  on  one  side  of  the  face.  The 
eyes  at  times  are  affected  with  cramp-like  contractions  of  the 
muscles  which  suggest  a  nystagmus.  The  pupils  in  the  early 
stages  react  immoderately  to  light ;  not  infrequently  a  hippus 
is  present.  The  tendon  reflexes  are  frequently  very  active,  in 
some  cases  exaggerated.  At  times  a  slight  ankle  clonus  may 
be  present.  There  may  be  cyanosis,  profuse  salivation,  and 
sweating.  The  rate  of  the  pulse  is  sometimes  quickened,  par- 
ticularly during  the  excited  periods,  and  the  blood-pressure  may 
be  low,  as  is  usually  seen  in  cases  where  the  motor  restlessness 
is  excessive.  Abnormally  low  temperatures  have  been  reported, 
especially  during  the  period  of  depression.  An  increase  of  tem- 
perature, if  it  persists  for  any  length  of  time,  should  at  once 


DEMENTIA    PRECOX 


403 


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Chart  to  illustrate  course  of  case  of  dementia  prsecox.  The  chart  shows  characteristic 
gain  and  loss  of  weight,  average  hours  of  sleep,  and  schematically  indicates  the  changes  in 
the  intellectual,  emotional,  and  motor  spheres.     The  patient  died  December  21,  1902. 


404 


PSYCHIATRY 


arouse  suspicions  of  tuberculosis,  a  disease  to  which  these 
patients  are  very  prone  (Kiernan).  In  the  acute  cases  the 
bodily  weight  not  infrequently  falls  rapidly  below  the  normal. 
In  the  more  chronic,  particularly  in  the  hebephrenic  type  of  the 
disease,  the  patients  may  become  quite  plump  and  fat. 

Etiology. — The  hereditary  factor  would  appear  to  be  of 
great  importance  in  the  genesis  of  this  disease.  Some  observers 
have  noted  evidences  of  alienation  in  the  progenitors  in  at  least 
75  per  cent,  of  their  cases  and  were  able  to  show  that  the  dis- 
ease was  endogenous  in  many  families ;  Bianchini 20  found  that 
hereditary  predisposition  was  present  in  nearly  all  of  his  cases. 
Mucha  affirms  that  among  the  ascendants  the  disease  was  of 
such  a  type  that  the  account  of  the  symptoms  given  was  suffi- 
ciently definite  to  justify  the  diagnosis  of  dementia  prsecox. 
Confinement  in  an  institution  was  not  considered  essential  for 
proving  the  existence  of  some  degree  of  this  form  of  mental 
aberration.  Thus  the  father,  mother,  brother,  or  sisters  were 
found  to  have  exhibited  abnormal  mental  characteristics,  such 
as  apathy,  a  singular  lack  of  initiative,  combined  with  the  occur- 
rence of  mannerisms,  stereotypies,  etc.  Burr 21  affirms  that 
"  onfy  he  who  is  preordained  can  acquire  the  disease." 

Apart  from  the  hereditary  basis  the  environment  of  the 
patient  is  of  the  greatest  importance.  Rapid  change  in  the  social 
condition  of  families  is  unquestionably  a  factor  of  great  etio- 
logical importance.  The  children  of  families  who  were  formerly 
poor  and  have  suddenly  come  into  the  possession  of  wealth  are 
particularly  prone  to  fall  victims  to  this  malady.  The  same  is 
equally  true  of  individuals  who  have  been  accustomed  to  a 
quiet  country  life  and  then  have  moved  to  large  cities,  where 
they  have  been  suddenly  subjected  to  new  and  entirely  altered 
surroundings.  In  the  discussion  of  catatonia  Kahlbaum  called 
attention  to  the  fact  that  the  disease  was  particularly  apt  to 

20  Sull  eta  compersa  e  sull'  influenza  dell'  ereditaria  nella  natogenesi 
della  demenza  primitive  o  precoce.  Riv.  sperim.  di  Freniatria,  vol.  xxix, 
fasc.  3,  1903. 

21  Burr,  Charles  W. :  University  of  Pennsylvania  Med.  Bull.,  March, 
1003. 


DEMENTIA    PRECOX 


405 


break  out  in  the  families  of  those  who  were  engaged  in  certain 
professions  or  trades,  and  affirmed  that  ministers,  teachers,  and 
their  children  were  particularly  liable  to  suffer  from  this  disease. 
Its  frequency  in  other  professions  has  also  been  noted ;  and,  in 
fact,  any  occupation  which  gives  rise  to  conditions  which  lower 
the  physical  activities  of  the  individual  while  unduly  stimulating 
the  functions  of  the  central  nervous  system  is  preparing  the 
soil  for  this  form  of  alienation.  According  to  Bianchini  and 
other  observers  the  mental  and  physical  development  of  those 
afflicted  with  the  disease  prior  to  the  outbreak  of  the  malady, 
except  the  catatonic  form,  has  been  normal.  All  physical  dis- 
orders which  cause  a  profound  anaemia,  disorders  of  digestion, 
and  those  occupations  which  cut  the  patient  off  entirely  from 
exercise  in  the  fresh  air,  long  periods  of  work  uninterrupted  by 
holidays,  trauma,  excesses  of  various  kinds,  infectious  diseases, 
particularly  influenza,  may  become  the  starting-point  of  this 
disease.  As  far  as  we  know  there  does  not  seem  to  be  any 
great  difference  in  the  frequency  with  which  the  malady  affects 
the  two  sexes.  Instances  of  this  form  of  mental  aberration 
are  said  to  have  followed  certain  surgical  operations.22  But 
although  this  statement  can  not  be  categorically  denied,  the 
present  evidence  upon  which  it  rests  is  too  limited  to  warrant  its 
acceptance.  That  operative  interference  has  merely  precipitated 
an  attack  of  catatonia  must  first  be  positively  excluded  before  it 
is  possible  to  affirm  that  catatonic  symptoms  are  the  direct  result 
of  injuries  inflicted  upon  the  central  nervous  system. 

The  differential  diagnosis  2S  when  the  disease  is  well  de- 
veloped is  not  particularly  difficult,  especially  if  stereotypies, 
mannerisms,  verbigeration,  and  negativism  are  present.  In  the 
early  stages,  however,  it  is  often  impossible  to  make  a  positive 
diagnosis  of  dementia  prsecox  until  the  patient  has  been  under 
observation   for  some  time.     At  first  the  protean  forms   of 

22  Bonhoffer,  K. :  Ueber  ein  eigenartiges  operativ  beseitigtes  kata- 
tonisches  Zustandbild.  Centralbl.  f.  Nervenheilk.  u.  Psych.,  Nr.  156,. 
Januar,  1903. 

23  Pritchard,  W.  H. :  Observations  on  Dementia  Prascox.  Cleveland 
Med.  Journ.,  January,  1904,  p.  18. 


4o6  PSYCHIATRY 

neurasthenia  have  to  be  considered.  The  occurrence  of  im- 
pulsive acts,  mental  depression  with  slight  apathy,  slow  psy- 
chical reaction,  the  appearance  of  mannerisms  and  the  like, 
however,  render  it  probable  that  the  case  is  one  of  dementia 
prsecox  and  not  a  purely  functional  disorder.  Not  infrequently 
hysterical  symptoms  complicate  the  question  and  increase  the 
difficulties  in  diagnosis,  since  they  often  are  met  with  during 
the  early  stages  of  dementia  prsecox.  Occasionally  we  have 
to  do  with  the  so-called  hysterical  insanity,  but  it  must  always 
be  remembered  that  this  form  of  alienation  is  comparatively 
rare  and  many  of  the  cases  formerly  classed  under  this  head 
are  now  known  to  be  dementia  prsecox.  Hysterical  symptoms 
do  not  necessarily  mean  an  hysterical  insanity. 

The  initial  stages  of  manic-depressive  insanity  and  de- 
mentia praecox  frequently  have  many  symptoms  in  common. 
The  motor  restlessness  of  the  former  presents  essential  differ- 
ences that  distinguish  it  from  the  quixotic,  volcanic,  emotional 
explosions  of  the  precocious  dement.  In  the  latter  group  of 
cases  the  acts  seem  to  be  the  result  of  an  inexplicable  im- 
pulsivity.  The  motor  agitation  is  not  so  constant;  there  are 
moments  of  quiet  and  apathy.  The  patients,  if  they  talk  at  all, 
give  expression  to  their  ideas  in  a  bizarre,  grotesque  manner. 
Frequently  the  hotch-potch  of  words  is  apparent.  In  the  ma- 
niacal cases,  on  the  other  hand,  there  is  the  typical  flight  of 
ideas  characterized  by  an  uninterrupted  flow  of  language.  The 
train  of  thought  deviates  rapidly  in  response  to  various  stimuli. 
In  the  dementing  cases  the  dissociation  is  the  prominent  fea- 
ture in  the  anomalous  physical  state.  The  typical  flight  of  ideas 
is  absent,  although  there  may  be  the  stereotyped  repetition  of 
certain  words  and  phrases.  Another  essential  difference  is  that 
in  the  maniacal  cases  the  emotional  no  less  than  the  intellectual 
state  is  in  a  measure  determined  by  the  patient's  environment. 
Maniacal  patients  see  something  that  pleases  them  or  arouses 
their  suspicions,  and  the  appropriate  emotional  tone  and  the 
corresponding  objective  expression  of  the  same  are  instanta- 
neously reflected  in  thought  and  act. 

In  the  dements  there  is  an  apparent  incongruity  or  dis- 


DEMENTIA    PRECOX 


407 


sociation  between  the  expression  of  the  mood  and  the  incident 
stimulus ;  the  emotional  change  is  frequently  foolish,  purpose- 
less, silly.  One  is  never  quite  sure  how  these  cases  will  respond 
to  stimuli.  In  those  afflicted  with  manic-depressive  insanity 
the  physician  is  frequently  able  to  say  in  advance  what  effect 
a  given  stimulus  will  have. 

The  differentiation  from  paresis  is  sometimes  difficult, 
particularly  in  the  juvenile  forms  of  the  disease.  The  speech 
and  action  of  the  paretic  may  at  times  become  decidedly  stereo- 
typed, but  never  to  the  same  degree  commonly  noticed  in  cases 
of  dementia  prsecox.  The  condition  of  the  pupils,  the  diminu- 
tion in  the  reaction  for  light,  the  involvement  of  the  cranial 
nerves,  and  the  speech  disturbances  are  important  diagnostic 
signs  of  paresis.  During  the  course  of  epileptic  mania  we  fre- 
quently meet  with  impulsive  acts  associated  with  great  violence. 
The  disorientation  of  the  epileptic  is  more  apt  to  be  complete. 
The  precocious  dement,  on  the  other  hand,  frequently  retains 
a  fairly  accurate  knowledge  of  his  environment  and  identity. 
Meyer  24  affirms  that  the  appearance  of  catatonic  symptoms, 
while  unfavorable,  does  not  necessarily  imply  that  the  case  is 
absolutely  incurable,  as  in  his  experience  from  20  to  25  per 
cent,  of  his  patients  who  have  shown  these  symptoms  after  a 
considerable  period  of  time  have  completely  recovered.  The 
hereditary  factor  is  an  important  element  in  at  least  54  per 
cent,  of  all  cases.  The  period  of  depression  in  the  dementing 
cases  may  be  distinguished  from  the  senile  melancholias  by 
the  occurrence  of  stereotypies,  negativism,  etc.  This  psychosis 
is,  as  a  rule,  distinguished  from  amentia  by  the  more  sudden 
onset  of  the  latter,  the  history  of  a  period  of  marked  physi- 
cal exhaustion,  the  number  as  well  as  the  dominating  force  of 
hallucinations  and  illusions,  and  the  marked  disturbance  in 
the  perceptive  processes  as  well  as  in  orientation.  The  differ- 
ential diagnosis,  however,  between  this  disorder  and  other  sub- 
acute delirious  or  confusional  states,  such  as  amentia,  is  fre- 


24  Zur  prognostisch.  Bedeut.  der  katatonisch.  Erschein.     Munch,  med. 
Wchnschr.,  1903,  Nr.  32. 


4o8  PSYCHIATRY 

quently  one  of  the  most  difficult  that  the  alienist  is  called  upon 
to  make.  There  is  little  doubt  that  isolated  catatonic  symptoms, 
such  as  verbigeration,  cerea  flexibilitas,  and  impulsivity  are  not 
infrequently  observed  in  the  latter  condition.  We  are  inclined 
to  agree  with  Stransky  25  that  amentia  is  not  as  uncommon  a 
disease  as  the  Heidelberg  statistics  seem  to  indicate,  it  having 
been  met  with  only  six  times  in  1500  cases.  In  two  instances 
which  within  the  past  year  have  fallen  under  our  observation 
the  patients  although  showing  catatonic  symptoms  ultimately 
recovered,  and  after  a  careful  examination  no  residual  mental 
defect  was  noted.  From  these  and  similar  observations  we 
are  led  to  believe  that  the  occurrence  of  isolated  catatonic  symp- 
toms does  not  necessarily  imply  the  existence  of  dementia 
prsecox. 

The  juvenile  cases  of  dementia  prsecox  bear  a  striking  simi- 
larity to  cases  of  imbecility.  The  diagnosis  depends  upon  the 
history  of  the  patient  and  the  occurrence  of  those  symptoms  to 
which  reference  has  so  frequently  been  made.  The  difficulties 
are  increased  in  cases  in  which  the  dementia  seems  to  be  en- 
grafted upon  a  preexisting  state  of  feeble-mindedness. 

Some  clinicians  have  attempted  to  establish  the  identity 
of  the  pathological  processes  concerned  in  the  production  of 
imbecility  and  certain  cases  of  dementia  prsecox.  This  error 
depends  in  a  measure  upon  the  failure  to  recognize  the  fact  that 
dementia  prsecox  not  infrequently  occurs  at  a  comparatively 
early  period  of  life.  These  juvenile  cases  dement  rapidly  and 
give  rise  to  a  chronic  state  which  presents  many  of  the  symp- 
toms common  to  imbeciles.  The  greatest  difficulty  in  diagnosis 
is  sometimes  met  with  in  the  more  protracted  cases.  As  Jahr- 
marker  26  has  pointed  out,  there  is  need  for  a  more  careful  study 
of  the  type  of  cases  now  grouped  under  the  head  of  dementia 
paranoides.  Only  after  the  lapse  of  months,  or  it  may  be  of 
years,  is  it  possible  to  determine  whether  the  disease  in  question 

25  Stransky,  Erwin :  Zur  Lehre  von  der  Dementia  Prsecox.  Centralbl. 
f.  Nervenheilk.  u.  Psych.,  1904,  Januar,  xvii.  Jahrg.,  N.  R,  Bd.  xv. 

24 Jahrmarker,  Max:  Zur  Frage  der  Dementia  Pracox.  Eine  Studie. 
Verlag  von  Carl  Marhold.     Halle  a/S.,  1903. 


DEMENTIA    PRECOX 


409 


should  be  grouped  under  the  head  of  paranoia  or  whether  there 
are  any  symptoms  which  suggest  catatonic  dementia.  In  regard 
to  these  cases  it  must  also  be  kept  in  mind  that  a  paranoiic  state 
does  not  warrant  the  diagnosis  of  paranoia. 

The  occurrence  of  isolated  catatonic  symptoms  during  the 
course  of  other  psychoses  has  been  frequently  observed.  Jahr- 
marker  27  has  noted  them  in  dementia  paralytica  and  reference 
has  already  been  made  to  their  appearance  in  amentia.  In  one 
case  that  came  under  observation  the  patient  presented  a  typical 
series  of  catatonic  symptoms  and  in  addition  Argyll-Robert- 
son pupils,  absence  of  the  patellar  tendon-reflex,  characteristic 
paretic  disturbances  of  speech,  and  a  definite  history  of  luetic 
infection  were  noted.  Such  a  combination  of  symptoms,  how- 
ever, naturally  suggests  the  possibility  of  a  complication.  In  the 
majority  of  cases  with  diminished  reflexes,  unequal  pupils,  and 
a  sluggish  reflex  for  light  we  are  justified  in  assuming  the 
presence  of  two  distinct  disease  processes.  Although  it  may 
be  admitted  that  isolated  catatonic  symptoms  occur  during  the 
course  of  other  psychoses,  this  does  not  justify  the  assumption 
that  the  simultaneous  or  consecutive  appearance  of  several  of 
these  symptoms  is  not  specific  of  catatonia.  As  far  as  we  are 
able  to  judge,  there  is  no  reason  for  believing  that  the  cata- 
tonic form  of  dementia  prsecox  may  not  complicate  other 
forms  of  insanity.  If  this  be  true,  the  catatonic  symptoms  are 
not  an  integral  part  of  the  clinical  picture  of  other  forms  of 
alienation.  The  nervous  manifestations  which  are  in  a  measure 
characteristic  of  the  earlier  cases  of  catatonia  are  increased 
tendon-reflexes  and  sometimes  widely  dilated  pupils. 

Pathology. — The  pathological  changes  noted  at  autopsy  in 
the  internal  viscera  of  patients  who  have  died  during  an  attack 
of  dementia  prsecox  are,  as  a  rule,  extensive,  but  neither  indi- 
vidually nor  collectively  are  they  specific.  Kiernan  was  the 
first  observer  to  call  attention  to  the  fact  that  cases  of  catatonia 
are  very  apt  to  have  tuberculous  infections. 

Dunton,  as  a  result  of  his  very  careful  studies,  reports  that 

27  Op.  cit. 


4io 


PSYCHIATRY 


there  is  a  general  but  not  excessive  series  of  alterations  in  the 
neural  elements.  The  nerve-cells  show  slight  central  chromo- 
lysis,  more  marked,  as  a  rule,  in  the  deeper  layers  of  the  cortex. 
Some  of  the  nuclei  are  swollen  and  there  is  a  folding  of  the 
nuclear  membrane.  Pale  yellowish  pigment  in  greater  amount 
than  occurs  in  the  nerve-cells  of  individuals  of  a  similar  age 
and  who  have  not  suffered  from  alienation  is  found.  These 
changes  are  also  noted  in  the  nerve-cells  of  the  basal  ganglia. 
Dunton  28  expresses  himself  very  conservatively  in  regard  to  the 
supposed  diminution  in  the  number  of  nerve-cells  in  the  cortex. 
In  some  instances  there  is  an  increase  in  the  number  of  neu- 
roglia cells  which  also  occasionally  give  evidence  of  mitotic 
division  (Alzheimer).  Neurophagocytosis  is  fairly  well 
marked.  In  one  case  Dunton  observed  "  decrease  in  the  num- 
ber of  Purkinje  cells,  and  those  present  were  distorted,  atro- 
phied, and  showed  the  condition  described  as  ghost  cells." 
The  vascular  changes,  if  they  exist  at  all,  are  unimportant. 
The  membranes  are  normal.  The  hypophysis  is  not  increased 
in  size.29 

Zacher  in  a  case  of  chronic  paranoia  terminating  in  de- 
mentia reported  a  moderate  degree  of  disappearance  of  the 
medullated  fibres  in  the  cerebral  cortex.  Analogous  conditions 
were  found  by  Cramer  in  two  cases.  In  the  first  case  the  de- 
menting process  followed  melancholia  and  in  the  second  a 
chronic  paranoia. 

Alzheimer  maintains  that  the  glia  changes  are  in  a  measure 
specific  and  that  the  severity  of  the  symptoms  is  in  a  measure 
proportional  to  the  extent  of  the  changes  in  these  elements. 
The  intensity  of  the  lesions  in  the  nerve-cells  runs  parallel  with 
the  changes  in  the  neuroglia  elements.  Vogt  has  reported  the 
pathological  findings  in  five  cases  of  dementia  prsecox  and  cata- 
tonia. In  one  case  the  cell  changes  were  scarcely  noticeable, 
but  in  the  others  the  chronic  cell  change  was  well  marked. 

28  Report  of  a  second  case  of  dementia  praecox  with  autopsy.     The 
Am.  Journ.  Insan.,  1904,  Ix,  No.  4. 

29  Dunton,  William  Rush,  Jr. :    Medical  Reports  of  the  Sheppard  and 
Enoch  Pratt  Hospital,  1903,  vol.  i,  No.  1. 


DEMENTIA    PRECOX  41 1 

There  was  an  increase  of  the  glia  throughout  the  outer  cortical 
layer  as  well  as  about  the  vessels.  In  one  of  the  cases  the  vessel 
wall  was  somewhat  thickened.  In  the  adventitia  there  was  a 
diminution  of  the  nuclei  and  a  considerable  amount  of  pigmen- 
tation. Practically  the  same  conditions  have  been  reported  by 
others.  The  investigations  of  Dunton  in  this  country  have 
added  materially  to  the  importance  of  the  above-mentioned 
findings  by  confirming  these  observations  in  cases  in  which 
careful  detailed  histories  were  given.  The  clinical  histories,  as 
well  as  the  general  pathological  findings,  all  tend  to  support  the 
hypothesis  that  the  disease,  at  least  in  its  incipiency,  is  an  auto- 
intoxication. 

Bernstein  30  has  recently  emphasized  certain  facts  in  the 
clinical  picture  which  seem  to  tend  to  strengthen  this  view.  On 
account  of  the  increased  mechanical  irritability  of  the  muscles  in 
the  catatonic  state  he  infers  that  the  hypertonia  is  due  in  part 
to  the  action  of  certain  toxic  agents  upon  the  neural  elements  in 
the  central  nervous  system.  The  muscular  phenomenon  is 
looked  upon  as  purely  psychomotor.  So  characteristic  are  these 
motor  symptoms  supposed  to  be  that  the  name  of  dementia 
paratonita  progressiva  or  paratonia  progressiva  has  been  sug- 
gested as  preferable  to  dementia  prsecox. 

Patini  and  Madia  31  as  a  result  of  their  investigations  con- 
clude that  the  catatonic  symptom-complex  is  the  product  of  an 
abnormal  psychosomatic  state  appearing  episodically  and 
standing  in  more  or  less  definite  genetic  relationship  to  the 
stupor.  According  to  the  same  view  the  catatonic  condition 
has  many  points  in  common  with  provoked  catalepsy  as  well  as 
with  the  phenomena  noted  in  somnambulism.  The  three  con- 
ditions of  catatonia,  catalepsy,  and  somnambulism  indicate  a 
lowering  of  certain  functions  of  the  brain  with  an  over-activity 
of  others,  and  as  a  result  of  this  there  are  a  disequilibration 
and  a  dissociation  of  the  cerebral  activity. 


30  Bernstein,  Alexander :    Ueber  die  Dementia  Pracox.    Allg.  Ztschr.  f. 
Psych,  und  psych. -gericht.  Medizin,  Bd.  lx,  Heft  4,  Berlin,  1903. 

31  Annali  di  Nevrologia,  1903,  anno  xxi,  fasc.  v,  vi. 


412 


PSYCHIATRY 


Treatment. — When  the  diagnosis  of  dementia  prsecox  is 
established  the  afflicted  individual,  if  possible,  should  be  trans- 
ferred to  a  hospital  for  the  insane  so  as  to  be  for  a  time  under 
constant  medical  supervision.  The  symptoms  should  be  studied 
with  a  view  to  determining  the  degree  of  liberty  that  may  with 
safety  be  given  to  the  sufferer.  In  the  milder  forms  of  the 
disease  there  is  sufficient  intellectuality  left  to  render  it  possible 
for  him  to  be  employed,  preferably  out-of-doors  in  work  about 
a  farm  or  garden.  Hard  physical  exercise  in  the  fresh  air 
seems  to  lessen  the  tendency  to  impulsivity  and  acute  exacer- 
bations of  the  disease.  These  mild  forms  of  the  disease  are 
peculiarly  well  adapted  for  treatment  in  the  colony  system. 
The  severer  types  are  best  off  either  in  a  hospital  or  an  asylum 
where  they  can  be  carefully  watched.  The  treatment  of  the 
symptoms,  as  they  arise,  is  purely  symptomatic.  As  this  form 
of  alienation  is  very  common  according  to  some  observers,  ex- 
clusive of  idiocy  and  imbecility,  making  up  about  one-fifth  to 
one-sixth  of  the  cases  admitted  to  hospitals  for  the  insane 
(although  this  is  probably  much  too  high  a  figure),  it  is  de- 
sirable that  the  characteristic  symptoms  should  be  recognized  as 
early  as  possible  by  the  general  practitioner.  A  comparatively 
large  number  of  cases  are  to  be  found  among  the  children  in  the 
public  schools.  The  tendency  to  emotional  outbreaks,  intellec- 
tual impairment,  looseness  in  morals,  should  be  sufficient  rea- 
sons for  the  immediate  removal  of  these  children  from  contact 
with  others. 


CHAPTER    XV 

THE  DEMENTIA  PARALYTICA  GROUP.       ( PARESIS.      PROGRESSIVE 
GENERAL   PARALYSIS    OF    THE   INSANE )  1 

Except  for  occasional  remissions  this  disorder  is  char- 
acterized by  a  group  of  mental  and  physical  symptoms  which 
tend  to  become  more  and  more  aggravated  until  a  peculiarly 
characteristic  dementia  supervenes,  to  be  followed  by  death  after 
a  period  varying  from  one  to  ten  or  more  years  from  the  onset. 
The  psychic  anomalies  are  the  result  of  a  more  or  less  general 
progressive  paralysis  of  the  cortical  functions  combined  with 
occasional  evidences  of  focal  lesions.  Pathological  changes  in 
the  brain,  medulla,  spinal  cord,  peripheral  nerves,  and  sympa- 
thetic system  are  common  and  frequently  extensive,  but  the 
totality  of  these  alterations  is  alone  distinctive.  The  beginnings 
of  our  knowledge  regarding  dementia  paralytica  are  supposed 
to  date  back  to  the  time  of  Thomas  Willis,  although  in  all  prob- 
ability the  earliest  authentic  descriptions  are  those  of  Haslam  in 
1798.  The  characteristic  speech  disturbance  was  first  noted  by 
Esquirol,  but  the  first  definite  attempt  to  differentiate  dementia 
paralytica  as  a  disease  entity  was  made  by  Bayle  in  1822,  and 
the  first  monograph  upon  this  subject  was  written  by  Calmeil 
in  1826.  Since  that  time,  both  in  the  clinic  and  laboratory,  a 
large  body  of  investigators  have  added  materially  to  our  knowl- 
edge of  this  disease,  so  that  at  present  it  has  probably  been  the 
subject  of  more  extended  study  than  any  other  form  of  aliena- 
tion. For  the  sake  of  clearness  brief  mention  will  first  be  made 
of  the  various  individual  symptoms,  but  the  discussion  of  their 

1V.  Krafft-Ebing:  Die  Progressive  allgemeine  Paralyse.  Holder, 
Wien,  1894.  Bannister,  H.  M. :  Reference  Handbook  of  the  Medical 
Sciences,  vol.  v.  New  York,  1902.  Dupre,  E. :  Paralysie  Generate  Pro- 
gressive. In  Ballet's  Traite  de  Pathologie  Mentale,  Paris,  1903,  pp.  884- 
1057- 

413 


414 


PSYCHIATRY 


relative  importance  and  the  different  ways  in  which  they  are 
apt  to  occur  will  be  reserved  until  we  come  to  deal  more  in 
detail  with  the  course  of  the  disease. 

Although  the  clinical  symptoms  of  general  paresis  which 
have  attracted  the  most  attention  are  those  developing  in  con- 
nection with  lesions  in  the  central  nervous  system,  clinicians  are 
gradually  becoming  convinced  that  more  care  should  be  be- 
stowed upon  the  study  of  disturbances  referable  to  disorders  in 
the  internal  viscera  even  in  the  earliest  stage  of  the  disease. 
The  clinical  picture  is  the  result  of  a  chronic  progressive  change 
in  the  nerve-elements,  and  although  this  deterioration  may  on 
superficial  examination  seem  to  be  more  marked  in  some  one 
part  of  the  nervous  system,  the  disease  process,  as  a  rule,  is  not 
localized,  so  that  symptoms  suggesting  focal  lesions  are  most 
commonly  to  be  regarded  as  the  result  of  complications.  The 
malady  progressively  affects  the  whole  psychic  life  of  the  indi- 
vidual, but  its  onset  may  be  most  insidious.  During  its  course 
anomalous  emotional  states  characterized  by  excitement,  de- 
pression, or  apathy  may  appear  with  accompanying  hallucina- 


1 "  • 

i 

"  '    h 

. 

5  ~ 

- 

f 

: 

;  1 ,  - 

- 

25    30    35    40    45    50   55    60 


Chart  I.     General  paralysis  in  women.    36  cases.     (After  Pickett.) 
The  figures  at  the  bottom  represent  the  ages ;  those  at  the  side  the  number  of  cases. 


tions  and  delusions,  but  later  on  there  develops,  more  or  less 
rapidly,  a  terminal  dementia  with  a  specific  stamp  and  distinc- 
tive physical  manifestations. 


DEMENTIA    PARALYTICA 


415 


Incidence  and  Etiology.2 — In  the  great  majority  of 
cases  the  disease  makes  its  appearance  in  the  third  and  fourth 
decades  of  life  at  the  time  when  the  intellectual  faculties  are 


28 

27 

26 

25 

24 

23 

22 

21 

20 

19 

18 

17 

16 

15 

14 

13 

12 

11 

10 

9 

8 

7 

6 

5 

4 

3 

2 

1 

t 

! 

■ 

1 

■  j 

i  H 

| 

! 

j 

1 

j  ':  1  ! ' 

k  r  i  ! 

^T 

;  j. 

! 

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— L_i__ 

'i 

H'' ' 

.  f 

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i 

.  25  30  35  40  45  50  55  60  i 

5 

Chart  II.     General  paralysis  in  men.     113  cases.     (After  Pickett.) 
The  figures  at  the  bottom  represent  the  ages  ;  those  at  the  side  the  number  of  cases. 

supposed  to  be  at  their  highest  stage  of  development  and  the 
individual  is  subjected  to  the  greatest  stress  and  strain  of  life. 
Undoubted  cases  occurring  as  early  as  the  first  or  second  and  as 


2  Die  Aetiologie  der  progress.   Paralyse. 
Wchnschr.,  1904,  Nr.  43. 


Raecke.     Psychiat.   Neurol. 


4i6  PSYCHIATRY 

late  as  the  fifth  or  sixth  decades  are  on  record,  but  are  relatively 
rare.  In  the  so-called  infantile  type  of  the  disease  hereditary 
syphilis  is  apparently  the  chief  factor  and  boys  and  girls  are 
about  equally  affected,  but  during  adult  life  it  is  six  or  seven 
times  more  common  in  men  than  in  women.3  Undoubtedly  the 
disease  is  now  recognized  more  frequently  in  women  than  for- 
merly, but  it  is  probable  that,  owing  to  the  marked  variations 
presented  in  the  disorder  as  it  affects  females  and  the  rare 
occurrence  of  a  marked  euphoria,  its  true  nature  was  not 
infrequently  overlooked.  V.  Kiss 4  gives  the  incidence  in 
women  as  compared  with  men  as  i  :  30.3,  while  Ringe°  found 
it  much  more  frequent,  1  15.6. 

As  regards  the  etiology  of  paresis  in  general  two  anti- 
thetical views  are  entertained,  some  authorities  holding  that 
syphilis  is  the  sole  cause  of  nearly  all  the  cases,  while  others 
minimize  the  significance  of  this  factor  and  assume  that  in 
at  least  half  of  the  cases  the  hereditary  predisposition  is  all- 
important.  In  any  case  the  latter  should  never  be  under- 
estimated. Nacke  6  has  referred  to  the  frequency  with  which 
stigmata  of  degeneration  are  observed.  The  general  con- 
sensus of  opinion  favors  the  view  that  the  family  history 
indicates  the  existence  of  nervous  or  mental  trouble  in  the 
ancestors  in  at  least  45  per  cent,  of  all  cases.  According  to 
Ziehen  signs  of  degeneracy,  while  more  common  in  paretics  than 
in  the  sane,  are  less  frequently  met  with  in  this  malady  than  in 
other  forms  of  alienation.  Other  observers  have  called  attention 
to  the  relative  infrequency  with  which  degenerates  are  afflicted 
with  paresis.  The  occurrence  of  the  disease  in  the  descend- 
ants of  those  who  have  suffered  from  paresis  is  not  infrequently 
reported,  although  they  are  more  particularly  apt  to  suffer 
from  various  functional  disturbances  of  the  nervous  system, 

aHoch,  August:    General  Paralysis  in  Two  Sisters.     Journ.  Nervous 
and  Mental  Disease,  1896. 

4  Orvosi  Hetilap.,  1904,  No.  7. 

5  Idem.,  1903,  No.  45. 

9  Die   sogenannten  ausseren   Degenerationszeichen  bei   der  p.    P.   der 
Manner.     Allg.  Ztschr.  f.  Psych.,  Feb.,  1899. 


DEMENTIA    PARALYTICA  417 

such  as  impaired  development,  alcoholism,  epilepsy,  etc.7  Since 
the  observations  of  Esmarch  and  Jensen8  it  is  obvious  that  in 
the  great  majority  of  cases  syphilis  is  an  important  etiological 
factor,  but  it  is  impossible  to  substantiate  the  view  that  all  others 
are  necessarily  of  secondary  importance.  The  statistics  upon 
this  point  vary  considerably.  Gudden  maintained  that  there 
was  a  definite  luetic  history  in  35.7  per  cent.,  Hirsch  in  56  per 
cent.,  Jolly  in  69  per  cent.,  Mendel  in  75  per  cent.,  and  Alz- 
heimer in  90  per  cent,  of  the  paretics  examined ;  nor  is  it  at  all 
improbable  that  in  a  varying  proportion  of  the  remaining  cases 
it  may  play  an  important  role,  although  it  is  impossible  to  either 
affirm  or  deny  its  existence.  Between  the  initial  sore  and  the 
outbreak  of  dementia  paralytica  a  long  period  may  intervene — 
on  an  average  from  ten  to  fifteen  years.  Hirschl  gives  the 
extreme  limits  at  from  two  to  thirty  and  v.  Kiss  at  from  one  to 
thirty-two  years.  It  is,  furthermore,  important  to  bear  in  mind 
the  fact  that  in  many  cases  it  is  impossible  to  say  that  the 
patient  has  not  previously  suffered  from  syphilis,  although  there 
may  be  complete  absence  of  positive  evidences  of  a  specific  in- 
fection. Some  alienists  affirm  that  neither  a  neuropathic  pre- 
disposition nor  the  syphilitic  infection  is  sufficient  to  account 
for  all  the  symptoms  that  develop  in  the  course  of  general 
paresis.9  The  observations  of  Scheube  10  are  of  considerable 
importance  as  showing  the  relative  frequency  of  syphilis  as  an 
etiologic  factor.  From  all  the  available  data  it  is  obvious  that 
paresis  is  relatively  rare  in  tropical  and  subtropical  countries 
and  among  half-civilized  peoples,  whereas  syphilis  is  very  com- 
mon. In  Abyssinia  Holzinger  was  unable  to  discover  a  single 
case  of  paresis  among  12,000  cases  of  syphilis.     Rothschuh 

7  Vallon  et  Wahl :  La  famille  des  paralytiques  generaux.  Congres 
de  Paris,  1900.  Arnauld:  La  descendance  des  paralytiques  generaux. 
Soc.  med. -psych.,  1899. 

8  Syphilis  u.  Geistesstorung.    Ztschr.  f.  Psych.,  Bd.  xiv,  S.  20. 

8  Coulon,  E. :  Nature  et  pathogenie  de  la  paralyse  generate.  Revue  de 
Psych.,  1902,  Nr.  10.  Hurd :  Etiology  of  Paresis.  Am.  Journ.  Insan.,  vol. 
lviii,  No.  4. 

10  Scheube,  R. :  Die  venerischen  Krankheiten  in  den  warmen  Lan- 
dern.    Arch.  f.  Schiffs  und  Tropen  Hygiene,  1902,  Bd.  vi,  Nr.  5-7. 

27 


418  PSYCHIATRY 

did  not  meet  with  any  case  of  the  disease  among  the  Nicara- 
guans,  although  it  was  estimated  that  at  least  70  per  cent,  of  the 
men  and  50  per  cent,  of  the  women  were  syphilitic.  Similar 
conditions  are  said  to  exist  in  Cashmere,  Siam,  Algiers, 
Egypt,  Southern  California,  and  Brazil.  The  same  is  true  in 
regard  to  the  negroes  in  countries  where  syphilis  is  common 
and  general  paresis  a  great  rarity.  Berkley  1X  and  Tschisch  12 
maintain  that  progressive  paralysis  is  merely  a  late  form  of 
syphilis  and  that  if  hereditary  lues  is  taken  into  account  this 
factor  covers  the  whole  field  of  the  etiology.  In  other  aliena- 
tions it  is  estimated  that  lues  is  an  etiological  factor  in  from  12 
per  cent,  to  18  per  cent,  of  all  the  cases. 

Instances  are  occasionally  reported  of  a  so-called  con- 
jugal paresis.13 

Chronic  alcoholism  is  a  factor  of  considerable  etiologic 
significance  and  is  probably  present  in  at  least  10  or  15  per 
cent,  of  all  the  cases  that  come  under  observation,  although 
some  authors  think  it  occurs  much  more  frequently.  Care  must 
be  taken,  however,  to  distinguish  between  the  drink  habit  which 
develops  as  a  result  of  the  disease  from  that  form  of  over- 
indulgence which  precedes  and  is  essentially  of  primary  causal 
importance. 

Trauma  is  supposed  by  some  to  be  solely  responsible  in 
a  very  few  cases  for  the  development  of  dementia  paralytica, 
but  although  it  may  properly  be  regarded  as  an  occasional  ex- 
citing agent,  it  is  not  in  any  sense  the  only  one.  A  majority 
of  the  cases  preceded  by  trauma  seem  to  develop  into  the  simple 
dementing  type  of  the  disease. 

The  importance  of  fatigue  as  a  provocative  agent  in  the 
genesis  of  the  disease  has  been  repeatedly  pointed  out,  but  there 

u  Berkley,  Henry  J. :  A  Treatise  on  Mental  Diseases.  D.  Appleton  & 
Co.,  1900. 

12  Tschisch,  W. :  Definition  of  Progressive  Paralysis ;  its  differentia- 
tion from  similar  forms  of  disease.  The  Journ.  of  Mental  Pathology, 
July,  1902. 

13  Ferenczi,  A. :  Budapester  konigl.  Aerzte-Gesellschaft,  Bd.  xvi,  1903. 
Cullerre,  A. :    Arch,  de  neurol.,  1904,  Fevrier. 


DEMENTIA    PARALYTICA  4I9 

are  some  observers  who  seriously  question  this  position  and 
maintain  that  this  factor  alone,  uncomplicated  by  other  con- 
tingencies, never  gives  rise  to  symptoms  that  are  suggestive  of 
general  paresis. 

Insolation  has  been  reckoned  of  considerable  etiologic 
importance,  Regis  and  others  holding  that  it  first  gives  rise  to 
a  toxaemia,  which  process  is  the  starting-point  of  the  disease. 
The  influence  of  chronic  lead  poisoning  has  long  been  recog- 
nized, but  it  must  always  be  borne  in  mind  that  many  of  the 
cases  reported  as  instances  of  paresis  are  in  reality  not  to  be 
distinguished  from  Korsakow's  psychosis.  In  Italy  pellagra 
has  often  been  known  to  precede  paresis.  As  a  rule,  the  social 
position  and  daily  life  of  the  individual  are  not  without  in- 
fluence. The  disease  is  uncommon  in  those  who  are  able  to 
lead  a  regular,  orderly  life,  but  is  very  frequent  among  soldiers, 
travellers,  journalists,  physicians,  and  those  whose  manner  of 
life  is  more  or  less  irregular.  Paresis  is  particularly  apt  to 
develop  among  men  in  the  higher  classes  of  society,  although 
women  in  the  same  grade  are  singularly  exempt.  Any  severe 
disease  which  lowers  the  vitality  of  the  individual  may  be  the 
exciting  cause.  Recently  English  observers  have  maintained 
that  gastro-intestinal  disturbances  play  an  important  role  in 
the  development  of  the  disease.14  The  statement  of  Bruce  and 
Robertson  that  the  disease  is  an  intoxication  caused  by  bacterial 
toxins  as  yet  can  not  be  substantiated,  and  there  is  little  evi- 
dence to  warrant  the  belief  that  B.  coli  is  an  important  etio- 
logical factor.  Bruce's  theory  that  the  normal  blood-serum 
causes  an  agglutination  of  B.  coli  more  readily  than  does  the 
serum  of  the  paretic  has  not  yet  been  generally  substantiated. 

The  sweeping  condemnations  sometimes  put  forth  by  cer- 
tain writers  against  the  evils  of  modern  civilization  and  their 
supposed  relation  to  the  marked  increase  in  the  number  of 
paretics  are,  in  view  of  the  paucity  of  facts,  of  little  scientific 
value.     The  more  general  recognition  of  the  disease  by  the 


14  Raimann,    E. :     Zur   Aetiologie    der   progressiven    Paralyse.      Wien. 
klin.  Wchnschr.,   1903,   Nr.   13. 


420 


PSYCHIATRY 


medical  profession  is  a  potent  factor  in  bringing  about  this 
apparent,  but  not  necessarily  actual,  increase  in  the  spread  of 
the  disease. 

Mental  Symptoms. — The  cardinal  defects  in  the  mental 
functions  that  appear  early  in  the  disease  and  in  nearly  all 
cases  form  the  basis  upon  which  the  more  complicated  psychic 
anomalies  develop  are :  ( i )  disturbances  in  the  power  of  atten- 
tion; (2)  amnesias;  (3)  defects  in  the  associative  processes 
largely  shown  in  the  inability  of  the  individual  to  form  mental 
syntheses;  (4)  changes  in  sensibility  and  in  the  so-called 
organic  sensations. 

( 1 )  The  inability  to  direct  the  attention  may  be  the  very 
first  symptom  of  the  disease.  At  first  the  patient  may  be  con- 
scious of  this  abnormality  and  lament  the  fact  that  he  is  unable 
to  keep  his  thoughts  focussed  upon  any  one  subject.  His  mind 
wanders,  and  every  attempt  to  focus  for  any  length  of  time 
upon  one  object  or  subject  is  accompanied  by  an  abnormal  sense 
of  effort.  The  more  intellectual  the  individual  the  sooner  does 
this  defect  become  apparent.  The  business  man  finds  that  he  is 
unable  to  conduct  his  own  affairs  or  to  concentrate  his  energies 
upon  the  accomplishment  of  a  single  aim,  inasmuch  as  he  is 
disturbed  by  the  constant  influx  of  new  stimuli  to  such  an  ex- 
tent that  he  soon  loses  track  of  the  goal  towards  which  he  has 
set  out.  This  distractibility  can  be  readily  demonstrated  by 
various  simple  tests.  For  example,  if  the  patient  is  asked  to 
add  up  a  long  column  of  figures,  it  not  infrequently  happens 
that  before  the  addition  is  completed  the  attention  is  deflected 
from  the  problem  either  by  the  cropping  into  consciousness  of 
some  new  idea  or  by  some  external  stimulus. 

(2)  As  a  result  of  this  defect  in  the  attention  the  memory 
early  shows  signs  of  being  seriously  disturbed.  These  amnesic 
defects  become  apparent  in  many  ways.  Thus  individuals  who 
in  both  conversation  and  writing  have  before  had  command  of 
a  large  and  varied  vocabulary  become  greatly  restricted  in  their 
use  of  words,  and  for  this  reason  may  complain  that  it  is  a 
great  effort  for  them  to  express  themselves.  These  disturb- 
ances in  composition,  to  which  more  detailed  reference  will  be 


DEMENTIA    PARALYTICA 


421 


made  later  on,  closely  resemble  those  seen  in  conditions  of  great 
physical  fatigue,  and  it  is  only  when  they  are  associated  with 
other  symptoms  that  they  become  of  diagnostic  importance. 
On  account  of  the  great  distractibility  of  the  individual,  new 
impressions  are  evanescent  and  are  seldom  retained.  The  more 
complicated  the  process  necessary  for  the  re-collection  and  re- 
development of  sensory  images  the  more  readily  does  the  dis- 
sociation become  evident.  Such  individuals  frequently  retain 
a  fairly  accurate  knowledge  of  events  that  have  occurred  in  their 
past  life,  while  the  present  is  more  or  less  of  a  blank.  The 
memory  for  faces  seen  only  once  or  twice  is  generally  soon 
blotted  out.  In  the  very  earliest  stages  patients  are  often 
greatly  distressed  by  this  defect,  since  they  realize  that  it  unfits 
them  for  the  successful  performance  of  their  ordinary  duties. 
The  lapses  of  memory,  as  a  rule,  are  progressive,  and  it  is  not 
rare  to  find  patients  who  forget  the  street  in  which  they  live  or 
are  unable  to  recall  the  names  of  the  various  members  of  their 
own  family.  Although  in  the  earlier  stages  the  patient  gen- 
erally retains  some  idea  as  to  the  importance  of  these  defects, 
and  either  tries  to  conceal  them  or  in  some  way  or  other  to 
divert  the  attention  of  the  observer,  later  on  the  consciousness 
of  their  existence  is  much  less  likely  to  awaken  a  very  great 
degree  of  emotional  disturbance. 

Aphasic  symptoms  may  intervene  but  are  indicative  of 
complications,  such  as  hemorrhage,  softening,  etc.  The  mem- 
ory defect  is  more  or  less  general,  involving  not  only  the  visual 
images  but  also  including  sounds.  The  memory  for  events  also 
suffers,  and  frequently  the  patient  is  unable  to  give  any  con- 
nected account  of  what  he  has  done  on  the  preceding  day  or  even 
in  the  past  hour.  In  spite  of  the  great  defect  in  recent  mem- 
ories there  is  often  a  remarkable  recollection  of  events  that 
have  occurred  in  the  remote  past. 

(3)  As  would  naturally  be  expected,  time  and  space 
orientation  are  also  seriously  interfered  with,  so  that  pa- 
tients find  themselves  unable  to  recall  the  year,  month,  and 
day  of  the  week,  and  may  be  equally  unoriented  as  to  their 
environment.    At  first  such  individuals  may  complain  that  their 


422  PSYCHIATRY 

surroundings  seem  strange  to  them,  but  cannot  give  any  defi- 
nite  idea  of  just  how  they  have  changed  except  that  per- 
sons no  less  than  familiar  objects  look  unnatural.     Gradually 
these  symptoms  increase  in  intensity  until  orientation  is  com- 
pletely destroyed  and  the  patients  fail  to  recognize  where  they 
are,  have  no  recollection  of  their  places  of  business,  do  not  re- 
member being  brought  to  the  hospital,  etc.    In  addition,  all  the 
memories  necessary  for  the  preservation  of  the  personal  identity 
are  apt  to  be  lost.    In  the  terminal  stages  associative  thought  is 
so  completely  disorganized  that  even  the  memories- of  events 
long  past  are  more  or  less  completely  obliterated.    These  anom- 
alies in  the  connection  of  ideas  appear  early  in  the  disease,  and, 
as  has  been  said  before,  there  is  often  a  subjective  recogni- 
tion of  this  by  the  patient,  who  is  himself  conscious  that  every 
mental  process,  particularly  if  it  is  at  all  complex,  is  only  accom- 
plished by  the  expenditure  of  an  abnormal  amount  of  energy. 
To  the  observer  the  actual  association  of  ideas  is  evidently 
slow  and  imperfect.     The  higher  the  intellectual  status  of  the 
individual  the  more  pronounced  does  this  defect  in  association 
become.     Partly  owing  to  the  distractibility  and  partly  to  the 
difficulty  in  association  the  amount  of  time  required  for  the 
completion  of  each  mental  process  is  very  greatly  increased. 
The  patients  complain  that  what  they  were  once  able  to  do  in  a 
few  minutes  now  may  take  them  an  hour  or  more.  They  can  not 
assign  a  definite  reason  for  this  mental  change,  although  they 
may  be  fully  conscious  of  the  fact  that  it  is  abnormal.     As  the 
disease  advances  the  defects  in  association,  which  are  at  first 
demonstrable  only  in  connection  with  the  more  complicated 
processes,  may  modify  even  the  simplest  mental  effort.    For  ex- 
ample, if  a  series  of  words  is  written  down  on  a  paper  and  the 
individual  is  asked  to  give  the  antithetical  word  or  phrase,  it  will 
be  noted,  as  a  rule,  that,  if  done  at  all,  this  is  accomplished  only 
with  the  greatest  difficulty.    Gradually  the  patient  becomes  un- 
able to  control  even  the  simpler  associations,  and  practically  all 
forms  of  connected  or  associated  thought  are  finally  abolished. 
Frequently,  however,  defects  in  the  ordinary  forms  of  associa- 
tion as  well  as  the  anomalies  in  the  mental  synthesis  and  in  the 


DEMENTIA    PARALYTICA 


423 


re-collection  and  redevelopment  of  past  events  are  in  part  hidden 
by  an  endeavor  on  the  part  of  the  patient  to  supply  the  breaks 
in  continuity  of  thought  by  flights  of  fancy.  Thus,  we  often 
encounter  individuals  who,  although  recognizing  the  attendants 
or  their  immediate  environment,  endeavor  to  fill  up  the  gaps  in 
memory  by  drawing  upon  their  imaginations  in  order  to  find  a 
plausible  explanation  for  circumstances  which  they  feel  to  be 
unsatisfactory.  As  the  dissociation  of  thought  continues, 
marked  confusion  and  a  true  primary  incoherence  may  result. 
(4)  Anomalies  of  sensation  are  not  uncommon  in  all  stages 
of  paresis,  but  on  account  of  the  mental  state  of  the  patient  it 
is  frequently  impossible  to  make  a  satisfactory  demonstration 
of  their  existence.  Sensation  for  touch,  temperature,  and  pain 
is  not  often  seriously  disturbed.  Marandon  de  Montyel,13 
after  making  careful  examinations  of  the  sensibility  in  a  com- 
paratively large  number  of  paretics,  has  come  to  the  conclusion 
that  whereas  touch  is  comparatively  normal  in  the  majority  of 
cases  during  the  whole  course  of  the  disease,  the  pain  sense  is 
disturbed  in  at  least  one-fourth  of  all  the  cases.  Somewhat 
rarely  hypsesthesias  or  analgesias  depending  upon  peripheral 
lesions  are  encountered,  whereas  hyperesthesias  are  said  to 
be  of  even  less  frequent  occurrence.16  Nevertheless,  it  is  prob- 
able that  the  psycho-anaesthesias,  psycho-parsesthesias,  and  psy- 
cho-hypaesthesias  are  of  far  more  frequent  occurrence  than  is 
commonly  believed.  The  so-called  coenesthetic  euphoria  re- 
ferred to  by  the  French  writers  undoubtedly  depends  upon  these 
psychic  disturbances,  and  in  the  more  advanced  stages  of  the 
disease  the  patients  not  infrequently  pound  themselves  with 
their  fists  or  purposely  inflict  some  injury  upon  themselves, 
actuated  by  the  mere  spirit  of  bravado  or  to  show  the  observer 
the  truth  of  their  claims  that  they  possess  qualities  superior  to 
those  of  the  ordinary  individual.  To  one  particular  form  of 
analgesia — an  anaesthesia  for  pain  on  pressure  over  the  ulnar 

15  De  revolution  comparee  de  la  sensibilite  etudiee  chez  les  memes 
maladies  aux  trois  periodes  de  la  paralyse  generale.  Bull,  de  la  societe 
de  med.  merit.,  Sept.,  1902. 

18  Ballet :    Traite  de  Pathologie  Mentale.     1903. 


424 


PSYCHIATRY 


nerve  as  it  passes  the  olecranon  process — first  noted  by  Biernaki 
in  1894  some  specific  diagnostic  importance  has  been  assigned 
by  some  authorities,  but  the  same  condition  has  been  noticed  in 
a  variety  of  other  forms  of  alienation. 

Psycho-parsesthesias  are  not  uncommonly  met  with,  the 
patients  complaining  of  vague  disturbances  in  various  portions 
of  the  body — formications  and  other  extremely  annoying  sen- 
sations. At  times  unpleasant  sensations  are  referred  to  the 
internal  viscera,  and  when  these  occur  in  the  later  stages  of  the 
disease  the  patients  endeavor  to  interpret  their  importance  in 
various  ways.  The  special  sense  organs  may  be  affected,  and 
hyperesthesias  as  well  as  paresthesias  of  the  retina,  of  the 
auditory  apparatus,  of  the  olfactory  tract,  are  not  rarely  met 
with. 

In  the  earlier  stages  the  hallucinations  are  very  apt  to 
belong  to  the  elementary  forms  and  may  be  associated  with 
touch,  sight,  hearing,  taste,  or  smell;  when,  as  occasionally 
occurs,  they  are  unilateral  in  character,  they  are  generally  con- 
nected with  disturbances  in  the  peripheral  tracts.  Recently 
attention  has  been  called  to  the  fact  that  hallucinations,  par- 
ticularly the  haptic  forms,  are  somewhat  more  common,  and 
Serieux  affirms  that  they  play  a  more  important  role  in  the 
genesis  of  the  delirious  states  than  was  originally  supposed. 
They  are  probably  most  common  in  cases  complicated  by  alco- 
holism and  other  toxic  conditions.  The  occurrence  of  psycho- 
motor hallucinations  has  been  referred  to  by  Seglas  and  other 
observers.  The  occurrence  of  these  as  well  as  the  auditory 
forms  is  not  infrequently  associated  with  certain  localized  dis- 
turbances in  the  corresponding  sense  area.  Not  infrequently 
during  the  course  of  the  disease  periods  occur  which  are  char- 
acterized by  a  great  exaggeration  in  the  intensity  of  the  hallu- 
cinations, so  that  there  develops  a  true  hallucinatory  mania. 

Marked  changes  in  the  organic  sensations  usually  develop 
early  in  the  disease.  This  is  particularly  true  in  regard  to  the 
increased  sense  of  fatigue;  in  fact,  in  a  number  of  cases  the 
presence  of  this  symptom  alone  in  the  absence  of  more  specific 
somatic  changes  may  render  it  impossible  to  determine  whether 


DEMENTIA    PARALYTICA  425 

we  are  dealing  with  a  neurasthenia  or  a  dementia  paralytica. 
This  sense  of  fatigue  is  common  not  only  after  mental  exertion, 
but  is  also  frequently  noticed  after  any  severe  physical  effort. 
On  the  other  hand,  at  a  still  later  stage  some  patients  instead  of 
complaining  of  fatigue  seem  to  be  entirely  devoid  of  this  sensa- 
tion. Effort  costs  nothing,  and  the  tireless  and  unremitting 
activity  of  such  individuals  is  strongly  suggestive  of  the  similar 
condition  which  ushers  in  an  attack  of  manic-depressive  insan- 
ity. Such  individuals  are  never  still,  constantly  planning  and 
undertaking;  they  are  living  examples  of  perpetual  motion. 
Occasionally  cases  are  met  with,  particularly  those  following 
trauma,  in  which  apathy  is  among  the  first  of  the  mental  symp- 
toms. Often  the  period  of  depression  or  exaltation  is  ushered 
in  by  one  characterized  by  an  excessive  irritability.  The  patient 
is  unable  to  perform  his  daily  duties,  since  every  trifle  is  a 
source  of  great  annoyance,  and  every  form  of  stimulation  seems 
to  evoke  an  abnormal  reaction.  The  simplest  interrogation 
arouses  an  immediate  sense  of  antagonism  and  may  provoke 
an  explosion  of  temper  accompanied  by  tremor,  reddening  or 
blanching  of  the  face,  and  all  the  visible  signs  of  great  anger. 
Such  individuals,  if  their  purposes  are  crossed,  are  very  apt  to 
resort  to  violence.  Not  infrequently  the  emotional  anomalies 
are  characterized  also  by  outbreaks  of  apprehensiveness  and 
marked  anxiety.  Sometimes  the  unpleasant  sensations  are 
referred  to  the  head  or  chest,  more  particularly  when  there  are 
marked  signs  of  disturbances  in  the  cranial  nerves  or  in  the 
circulation.  Frequently,  however,  the  anxiety  and  appre- 
hensiveness is  general  in  character  and  may  be  directly  asso- 
ciated with  and  apparently  induced  by  one  of  the  explosive 
outbursts  of  temper.  These  emotional  disturbances  may  persist 
for  some  time  and  may  then  be  followed  by  the  depression  or 
exaltation. 

These  more  or  less  primary  defects  in  the  mental  facul- 
ties give  rise  to  a  great  variety  of  changes  in  the  character, 
which  vary  somewhat  with  the  social  as  well  as  the  intellectual 
status  of  the  individual ;  hence  the  ability  of  the  physician  to 
recognize  the  condition  will  depend  to  some  extent  on  a  knowl- 


426  PSYCHIATRY 

edge  of  the  individual  prior  to  the  onset  of  the  disease.  The 
primary  disturbances  in  the  personality  are  characterized  by  a 
lack  of  judgment.  The  patient  begins  to  lose  his  sense  of  pro- 
portion, of  the  relative  value  of  things  in  general;  his  higher 
moral  sense  becomes  blunted ;  the  sense  of  duty  is  diminished  or 
entirely  absent;  business  interests,  professional  engagements, 
social  and  family  ties,  are  ignored.  As  a  rule,  the  earliest  dis- 
turbances are  confined  to  the  autopsychic  consciousness.  There 
is  a  change  in  the  conditions  which  determine  the  personality  of 
the  individual.  Such  patients  are  apt  to  become  egotistical. 
They  are  self-centred,  but  except  in  a  certain  set  of  cases  there 
is  an  absence  of  hypochondriacal  sensations.  The  sense  of  well- 
being  is  exaggerated,  and  in  contrast  with  hypomania  is  apt 
to  be  persistently  and  consistently  magnified.  The  patients  are 
intent  on  carrying  out  some  new  plan  or  scheme  connected  with 
their  business.  They  affirm  that  the  great  opportunity  in  life, 
for  which  they  have  long  waited,  has  at  last  come.  For  years 
they  have  been  getting  ready  to  meet  such  an  emergency,  and 
they  undertake  any  extravagant  scheme  without  considering  the 
probability  of  failure  and  with  indomitable  assurance  that  the 
ultimate  success  of  their  ventures  is  merely  a  question  of  time. 
At  first  this  abnormal  self-reliance  becomes  apparent  only  in 
certain  directions,  generally  along  the  lines  in  which  the 
patient's  activities  have  been  most  prominently  directed  prior  to 
the  onset  of  the  disease. 

Not  uncommonly  the  apparent  increase  of  energy  in  an 
individual  is  a  source  of  wonder  to  his  friends  or  business  asso- 
ciates. At  first  the  abnormality  characterizing  the  acts  or 
physical  processes  of  the  individual  does  not  become  apparent, 
and  the  failure  on  the  part  of  the  medical  attendant  to  recognize 
an  incipient  case  of  paresis  frequently  gives  rise  to  serious 
results  financially,  particularly  if  the  individual  has  been  able 
to  impress  trusting  associates  with  the  apparent  practicability 
and  ease  with  which  his  countless  schemes  can  be  successfully 
carried  through.  Not  infrequently  in  these  earlier  stages,  asso- 
ciated with  the  defects  already  enumerated,  such  individuals 
show  a  marked  tendency  towards  alcoholism,  and,  as  a  rule, 


DEMENTIA    PARALYTICA  427 

are  particularly  susceptible  to  the  toxic  effects  of  the  drug. 
In  most  of  the  cases  various  sexual  irregularities  make  their 
appearance — urinating  in  public  before  women,  exhibitionism, 
the  loss  of  all  sense  of  decency,  uncontrollable  erotic  impulses 
that  may  result  in  assaults  upon  young  women  or  children, 
and  sexual  perversity.  Later  the  period  of  excess  is  followed 
by  a  marked  diminution  of  the  sexual  appetite  and  impotence. 
The  insane  ideas  that  occur  during  the  course  of  the  disease 
are  very  varied  in  character  and  some  have  long  been  regarded 
as  being  in  a  sense  specific.  This  is  particularly  true  of  the 
forms  which  will  be  described  later  when  dealing  with  the  ex- 
pansive type  of  the  disease.  These  ideas  are  apt  to  be  largely 
colored  by  the  emotional  tone  of  the  individual.  For  example, 
in  the  states  of  depression  the  individual  is  possessed  by  hypo- 
chondriacal ideas,  by  curious  notions  regarding  his  own  per- 
sonal identity,  or  more  or  less  typical  nihilistic  ideas ;  while  in 
the  expansive  stage  the  euphoria  is  accompanied  by  ideas  which 
equally  reflect  the  delirium.  Their  genesis  has  been  studied  by 
numerous  authors,  but  considerable  discrepancy  still  exists  as  to 
the  exact  manner  in  which  they  develop.17  Wizel  as  a  result  of 
a  careful  study  has  come  to  the  conclusion  that  the  disorien- 
tation in  time  and  space,  to  which  reference  has  been  made, 
is  in  part  responsible  for  the  development  of  the  more  or  less 
characteristic  insane  ideas.  Another  important  factor  in  their 
pathogenesis,  according  to  the  same  author,  is  the  anomaly 
in  the  stereometric  sense  as  well  as  the  defects  in  memory. 
These  defects  give  rise  secondarily  to  exaggerations  of  the  time 
and  space  sense  that  become  evident  in  the  extraordinary  char- 
acter of  the  delirium.  As  a  result  of  these  mental  anomalies 
the  paretic  suffers  from  a  general  dissociation  of  both  abstract 
and  concrete  ideas.    Gross,18  on  the  other  hand,  maintains  that 

17  Storrung,  Gustav :  Vorlesungen  iiber  Psychopathologie  in  ihrer  Be- 
deutung  fur  die  normale  Psychologic  Leipzig,  1900.  Wizel,  Adam : 
Ueber  die  Pathogenese  des  specifischen  Warms  bei  Paralytikern.  Ein 
Beitrag  zu  psychologisch  experimentellen  Untersuchungen  iiber  die  De- 
mentia paralytica.    Neurol.  Centralbl.,  1903,  August  1,  Nr.  15,  S.  723. 

18  Gross,  Otto :  Ueber  die  Pathogenese  des  specifischen  Wahns  bei 
Paralytikern.     Neurolog.  Centralbl.,  1903,  September  1,  Nr.  17,  S.  843. 


428  PSYCHIATRY 

the  mode  of  development  of  these  ideas  is  essentially  different 
from  that  in  other  forms  of  mental  disturbance.  This  delirium 
is  not  in  any  respect  an  attempt  on  the  part  of  the  patient  to 
explain  the  strange  ideas  which  are  forced  into  his  conscious- 
ness, but  is  to  be  regarded  as  the  result  of  a  process  similar 
to  that  occurring  in  hysterical  individuals  who  narrate  the 
most  extraordinary  adventures  without  any  foundation  of 
truth.  Both  phenomena  are  merely  the  product  of  the  im- 
agination. In  addition  to  these  insane  ideas  which  are  char- 
acterized by  their  strangeness  and  incoherency  we  frequently 
meet  with  other  forms  similar  to  those  developing  in  para- 
noic states,  these  latter  being  the  result  of  an  attempt  at 
explanation  on  the  part  of  the  patient  of  the  isolated  facts  in 
his  consciousness. 

Somatic  Symptoms.  Disturbances  of  Motility. — 
Among  the  abnormal  motor  manifestations  are  tremor  and 
incoordination  of  the  muscles  of  the  trunk,  extremities,  face, 
tongue,  and  those  connected  with  speech  and  deglutition.  The 
disturbances  are  very  varied  and  depend  in  great  measure  upon 
the  localization  of  the  disease  process.  The  cases  in  which  the 
pathological  changes  affect  the  spinal  cord  naturally  afford  a 
great  variety  of  neurological  symptoms.  Closely  associated 
with  the  cortical  changes  in  all  cases  of  paresis  a  slight  inco- 
ordination of  all  muscular  movements  not  uncommonly  de- 
velops. This  is  particularly  apt  to  first  make  itself  noticeable 
in  connection  with  the  more  complicated  procedures,  such  as 
the  finer  movements  of  the  fingers,  the  contraction  of  the  facial 
muscles,  and  those  concerned  in  the  coordination  of  the  move- 
ments of  the  eye.  The  tremor,  which  is  present  in  a  large  num- 
ber of  cases,  is,  as  a  rule,  fairly  rapid — from  four  to  six  or 
more  oscillations  in  a  second.  It  may  be  easily  demonstrated 
by  making  the  patient  extend  his  arms,  stretch  out  his  fingers, 
or  protrude  the  tongue;  and  even  if  not  at  first  apparent  in  the 
muscles  supplied  by  the  facial  nerve,  it  may  be  brought  out  by 
asking  the  patient  to  show  his  teeth,  not  allowing  him  to 
actually  touch  them  with  his  lips  and  thus  steady  his  move- 
ments.    This  method  is  frequently  sufficient  to  demonstrate 


DEMENTIA   PARALYTICA  429 

the  existence  of  a  marked  tremor  in  the  region  of  the  labionasal 
fold,  and  may  also  be  observed  in  the  lips  and  when  more  intense 
in  the  muscles  about  the  eyes,  particularly  in  the  lids;  occa- 
sionally it  is  well  marked  in  the  region  of  the  frontalis.  Fibril- 
lary tremors  in  the  muscles  sometimes  exist.  Generally  the  con- 
tractions are  slow,  but  this  apparent  interference  with  function 
is  apt  to  be  largely  superficial  and  does  not  seem  to  involve  the 
deeper  layers  of  the  musculature.  The  tremor  of  the  tongue  is 
frequently  so  marked  as  to  be  a  source  of  great  annoyance  to 
the  patients,  and  they  will  often  try  to  conceal  it  when  talking 
by  opening  the  mouth  very  widely  and  protruding  the  tongue, 
their  attempts  to  steady  it  giving  rise  to  the  most  curious  gri- 
maces, which  should  readily  excite  our  suspicions.  It  is  a  matter 
of  common  experience  that  the  tremor  is  not  always  constant 
but  varies  considerably,  its  extent  depending  more  or  less 
directly  upon  the  general  physical  condition.  At  certain  times 
movements  of  incoordination  seem  to  be  more  marked,  and 
frequently  one  can  notice  slight  spasmodic  disturbances  in  the 
musculature  which  assume  a  more  or  less  clonic  character. 

The  gait  of  the  paretic  is,  as  a  rule,  characterized  by  some 
uncertainty,  the  degree  depending  largely  upon  the  extent  of 
involvement  of  the  cord  centres.  As  a  rule,  all  grace  and 
delicacy  of  movement  seem  to  be  lost  early,  and  the  individual 
who  prior  to  the  onset  of  the  disease  showed  refinement  and 
good  social  breeding  becomes  awkward  and  clownish  in  his 
manners  and  appears  ill  at  ease. 

The  electrical  response  of  the  muscles  in  cases  of  general 
paresis  uncomplicated  by  disturbances  in  the  peripheral  nerves 
as  a  rule  show  no  marked  or  specific  change.19  Lenzi20  and 
other  observers  have  noticed  a  partial  reaction  of  degeneration 
in  the  terminal  stages. 

Not  infrequently  a  spasmodic  contraction  can  be  noticed 
in  various  parts  of  the  body,  and  it  is  probable  that  this  phe- 

19  Pilcz,    A. :     Ueber    Ergebnisse    elektrisch    Untersuch.    bei    Paralys. 
Progress  u.  Dement,  senilis.    Jahrbucher  f.  Psych,  u.  Neurol.,  1903. 

20  Delia    reazione    eletrica    nerv.    e    musculare   nelle   paralisi    generale 
progressiva  degli  alienati.     Ann.  di  Nevrol,  1899. 


43° 


PSYCHIATRY 


nomenon  is  not  always  confined  to  the  musculature  of  the 
trunk  and  extremities,  but  occasionally  implicates  the  muscles 
of  the  bladder  and  other  internal  organs.  Occasional  instances 
of  catatonic  rigidity  have  been  reported,  but  the  histories  of 
the  cases  in  which  this  is  said  to  have  occurred  are  not  given 
in  sufficient  detail  to  warrant  the  deduction  that  the  typical 
form  is  ever  noticed  in  the  course  of  general  paresis. 

Disturbances  in  Speech. — The  anomalies  of  movement  are 
particularly  liable  to  implicate  the  musculature  of  the  organs 
concerned  in  speech  and  manifest  themselves  mainly  in  diffi- 
culty in  articulation  and  enunciation  (dyslalise).  They  must 
not  be  confused  with  the  dysphasias  or  dyslogias  which  have 
to  do  with  impairment  of  the  sensory  functions  of  speech. 
These  disturbances  are  unquestionably  due  in  part  to  the 
interference  with  the  functions  of  the  cerebral  cortex.  The 
dyslalia,  or  dysarthria,  at  first  is  merely  an  exaggeration  of  the 
muscular  disturbances  resulting  from  fatigue.  The  patient 
when  asked  to  pronounce  long  words,  such  as  Rappahannock 
River,  parallelopiped,  finds  considerable  difficulty  in  enunciating 
clearly  and  distinctly.  As  a  result  there  is  a  marked  tendency 
to  drop  certain  syllables  and  slur  others.  The  difficulties  are 
frequently  increased  if  the  patient  has  been  previously  fatigued 
as  the  result  of  mental  or  physical  effort.  When  the  disturb- 
ance in  speech  is  marked,  the  attempt  to  enunciate  is  accom- 
panied by  an  increase  of  the  tremor  of  the  lips  and  marked 
incoordination  of  the  muscles  concerned.  The  patient  not  in- 
frequently affirms  that  his  tongue  feels  thick  or  that  the  attempt 
to  enunciate  clearly  is  accompanied  by  a  definite  sense  of 
fatigue.  The  dysphasias  are  analogous  to  many  of  the  disturb- 
ances noted  in  sensory  aphasia.  The  occurrence  of  motor 
aphasia  generally  indicates  the  presence  of  a  complication.  The 
dyslogias  are  shown  in  the  manner  of  speech;  for  example, 
during  the  period  of  marked  euphoria  the  enunciation  is  apt  to 
be  slow  and  special  emphasis  is  laid  on  certain  words.  The 
speech  is  not  accompanied  by  refinement  of  manner  or  gesture, 
while  in  the  periods  of  depression  it  is  even  more  monotonous 
and  may  be  replaced  by  periods  of  mutism.    Many  authors  have 


DEMENTIA    PARALYTICA 


431 


called  attention  more  particularly  to  the  peculiar  intonation  of 
paretics.  Maranclon  de  Montyel  21  has  recently  made  this  the 
subject  of  special  investigation.  Only  in  a  small  proportion  of 
the  cases,  about  one-third,  is  the  character  of  the  voice  un- 
changed. In  some  cases  the  alteration  is  permanent,  while  in 
others  there  are  periods  of  exacerbations  and  remissions  in  the 
defects,  the  former,  as  a  rule,  being  much  longer  than  the  latter. 
According  to  the  same  observer  these  vocal  disturbances  are 
much  more  apt  to  occur  in  the  second  than  in  the  first  period, 
while  in  the  final  stage  motor  troubles  become  extreme.  The 
phonograph  has  proved  of  great  service  in  recording  the  char- 
acter of  the  speech  disturbances. 

Disturbances  in  Writing. — These  are  similar  to  those 
noticed  in  connection  with  speech,  and  as  a  French  observer  has 
aptly  said,  "  the  style  is  the  man."  The  purely  cortical  disturb- 
ances cause  dissociation  of  thought,  so  that  attempts  on  the  part 
of  the  patient  to  write,  aside  from  the  mere  mechanical  execu- 
tion, necessitate  marked  effort.  Furthermore,  the  modifications 
in  the  method  of  expression  reflect  the  emotional  and  mental 
state  of  the  individual.  Marked  exaggeration  or  hyperbole  is 
characteristic  of  the  period  of  expansiveness,  while  the  reverse 
is  true  for  the  state  of  depression.  The  movements  in  holding 
the  pen  as  well  as  in  the  actual  execution  of  the  letters  are 
coarse  and  incoordinated,  and  in  the  severe  cases  these  defects 
become  so  exaggerated  that  the  writing  is  illegible.  The  same 
tendency  shown  towards  the  omission  of  syllables  becomes 
noticeable  in  the  writing.  Defects  in  spelling  and  orthography 
may  become  pronounced.  The  example  of  handwriting  which 
follows  illustrates  the  character  of  the  changes. 

In  addition  to  the  disturbances  in  motility,  already  noted, 
we  not  infrequently  meet  with  a  slight  paresis  of  the  muscles 
supplied  by  the  facial  nerve.  This  is  generally  unilateral  and 
gives  rise  to  marked  facial  asymmetry.    The  space  between  the 


21  Contribution  a  l'etude  des  alterations  de  la  voix  dans  les  premieres 
periodes  de  la  paralysie  generate.  Journal  de  Neurologie,  1903,  Nov.  5, 
No.  21. 


432 


PSYCHIATRY 


lids  is  often  increased,  owing  either  to  a  paresis  of  the  orbicu- 
laris or  to  a  drooping  of  the  under  lid.  Sometimes  the  uni- 
lateral asymmetry  becomes  noticeable  only  when  the  patient 
attempts  to  speak  or  pucker  his  lips,  to  whistle,  or  to  protrude 


No. 


THE    JOHNS    HOPKINS    HOSPITA 
DISPENSARY 

Date, 


Handwriting  from  case  of  dementia  paralytica  to  illustrate  excessive  tremor. 

the  tongue.  Disturbances  of  the  ocular  muscles  are  not  infre- 
quent, and  temporary  paresis  of  those  supplied  by  the  third 
and  sixth  nerves  is  of  considerable  diagnostic  importance 
(Hiram  Woods).22  The  paralyses  that  occur  as  the  result  of 
complications  will  not  be  described  in  full  here,  a  comprehensive 
account  being  available  in  the  various  articles  and  text-books 
on  neurology.  The  general  muscular  power,  as  a  rule,  is 
diminished,  although  single  muscles  or  groups  are  more  affected 
than  others.  It  may  be  said,  however,  that  a  definite  mono- 
plegia or  hemiplegia  is  to  be  regarded  as  an  evidence  of  a 
focal  lesion. 

Disturbances  of  Vision. — The  disturbances  of  vision  that 
occur  during  the  course  of  paresis  are  frequent  and  varied  in 
character.  Frequently  in  the  early  stages  we  meet  with  disturb- 
ances in  the  mental  processes  connected  with  the  visual  pro- 
cesses that  are  suggestive  of  the  functional  disorders  noticed  in 


22  Schmidt-Rimpler,  H. :    Die  Erkrankungen  des  Auges  im  Zusammen- 
:hang  mit  anderen  Krankheiten.    Wien,  1898. 


DEMENTIA    PARALYTICA  433 

neurasthenia  and  hysteria.  Associated  with  attacks  of  mi- 
graine, which  are  not  uncommon,  are  encountered  a  great 
variety  of  visual  anomalies  which  are  ordinarily  associated  with 
these  attacks  and  are  probably  caused  by  the  action  of  certain 
toxic  substances  upon  the  visual  cortex. 

Inequality  of  the  pupils  is  frequently  noted  and  when  well 
marked  is  of  considerable  diagnostic  importance  when  taken 
in  conjunction  with  other  symptoms.  Not  only  is  an  inequality 
frequently  noticeable,  but  the  outlines  of  the  pupil  are  also 
irregular.  In  the  earliest  stages  of  the  disease,  particularly  at 
the  time  when  the  neurasthenic  symptoms  are  marked,  the  light 
reflex  is  often  very  active  and  sometimes  a  definite  hippus  is 
present.  Following  this  period  the  reflexes  for  light  may  grad- 
ually become  more  and  more  sluggish,  until  at  last,  after  vary- 
ing intervals  of  time,  the  light  reflex  may  disappear  altogether 
although  accommodation  is  retained.  The  typical  Argyll- 
Robertson  pupil,  however,  seldom  appears  except  in  the  cases 
which  begin  with  tabetic  symptoms.  An  inequality  and  irregu- 
larity of  the  pupils  with  a  diminished  light  and  accommodation 
reflex  probably  form  the  most  common  combination  of  symp- 
toms. The  so-called  paradoxical  light  reflex — the  pupil  not 
contracting  when  suddenly  exposed  to  a  bright  light  but  dilating 
shortly  afterwards — has  been  noted  in  some  instances.  This 
whole  subject  has  been  reviewed  by  Piltz,23  who  affirms  that  the 
true  paradoxical  light  reflex  is  a  very  exceptional  symptom  and 
occurs  only  in  association  with  severe  organic  lesions  of  the 
central  nervous  system.  It  may  easily  be  confused  with  the 
change  that  occurs  in  the  pupils  on  convergence,  divergence, 
or  with  the  hippus,  as  well  as  with  the  effect  produced  by  heat 
stimulation  of  the  sympathetic  and  the  so-called  orbicular  reac- 
tion. 

Atrophy  of  the  optic  nerve  occasionally  occurs,  but  is  not 
nearly  as  common  as  it  is  in  tabes.  It  should,  however,  be  stated 
that  some  observers  have  reported  its  occurrence  with  much 


Neurolog.  Centralbl.,  1902,  Nov.  1,  Nr.  21,  and  Nov.  16,  Nr.  22. 

28 


434 


PSYCHIATRY 


greater  frequency.  Keraval  and  Raviart  24  maintain  that  the 
sclerosis  of  the  optic  nerve,  when  it  does  occur,  may  be  either 
insular  or  annular  in  character.  In  all  probability  it  is  more 
common  in  patients  who  have  not  come  under  medical  treat- 
ment until  late  in  the  disease.  This  conclusion  is  based  upon 
the  fact  that  it  is  much  more  commonly  observed  in  public  insti- 
tutions where  the  patients  are  only  received  after  the  disease  is 
well  along  in  the  second  stage  than  in  private  hospitals  where 
patients  are  accepted  at  a  much  earlier  period.  These  same 
observers  25  affirm  that  the  fundus  is  normal  in  38  per  cent,  of 
the  paretics  that  have  come  under  their  observation. 

Reflexes. — The  reflexes  in  general  paresis  have  been 
studied  by  numerous  observers,  and  the  character  of  the  dis- 
turbance noted  has  been  found  to  depend  largely  upon  the  char- 
acter and  extent  of  the  spinal  cord  lesions.  In  the  cases  compli- 
cated by  tabetic  changes  the  deeper  reflexes  may  be  diminished 
or  abolished  in  the  later  stages,  although  before  they  may  have 
been  increased.  Not  infrequently  the  deep  reflexes  are  tempo- 
rarily abolished.  This  is  particularly  apt  to  be  the  case  when 
sugar  appears  temporarily  in  the  urine — in  the  so-called  pseudo- 
pareses  of  diabetic  origin.  The  statistics  regarding  the  num- 
ber of  cases  in  which  the  deep  reflexes  are  impaired  or  abolished 
vary  considerably,  a  difference  that  depends  largely  upon  the 
stage  of  the  disease  at  which  the  observation  is  made  as  well  as 
upon  a  number  of  other  conditions,  such  as  the  variations  in  the 
type  of  the  disease  in  different  localities.  In  fully  one-half  of 
the  cases  the  reflexes  are  increased  or  exaggerated.  This  is  in 
part  due  to  the  absence  of  the  ordinary  cortical  inhibition  as 
well  as  to  the  lesions  in  the  lateral  pyramidal  tracts.  The  super- 
ficial reflexes — more  especially  the  pharyngeal  and  cremasteric 
— are  frequently  altered,  so  that  early  in  the  disease  it  is  not 
uncommon  to  find  them  greatly  exaggerated.  The  Babinski 
reflex  may  or  may  not  be  demonstrable. 

"Keraval  et  Raviart:  Etat  du  fond  de  l'oeil  chez  les  paralytiques 
generaux  et  les  lesions  anatomiques  initiales  et  terminales.  Archives  de 
Neurol.,  1903,  Janvier. 

25  Arch,  de  Neurol.,  1904,  Mars,  No.  99. 


DEMENTIA    PARALYTICA  435 

Vasomotor  and  trophic  disturbances  are  present  in  nearly 
all  cases  and  are  very  varied  in  character.  Disturbances  of  the 
circulation,  most  marked,  as  a  rule,  in  the  head,  face,  and  ex- 
tremities, are  relatively  common.  Sometimes  there  is  a  slight 
cyanosis  of  the  face  and  associated  with  it  an  oedema  of  the  eye- 
lids not  infrequently  resulting  in  an  apparent  ptosis.  It  is  true 
that  similar  disturbances  are  found  in  other  psychoses,  never- 
theless, their  importance  should  not  be  underestimated  as  an 
aid  to  diagnosis  in  the  very  early  stages  of  the  disease.  The 
occurrence  of  these  congestions  and  localized  cedemas  is  ex- 
plained by  a  number  of  observers  as  the  result  of  a  paresis 
affecting  the  vasomotor  system.26  Not  infrequently  a  diffuse 
sweating  may  be  noticed,  which  is  particularly  apt  to  occur  after 
the  subsidence  of  an  emotional  outbreak.  The  sweating  in 
some  cases  is  localized,  being  confined  to  certain  portions  of  the 
body,  but  occasionally  a  marked  unilateral  hyperidrosis  is  noted. 
Numerous  writers  have  referred  to  the  importance  of  hema- 
toma auris  in  paresis  as  well  as  in  other  psychoses,  but,  as 
Robertson  has  shown,27  the  occurrence  of  these  othsematomata 
is  wrongly  attributed  to  vasomotor  disturbances,  observations 
having  shown  this  phenomenon  to  be  the  result  of  degeneration 
in  the  cartilaginous  substance  of  the  ear.  Sometimes  an  ab- 
normal dryness  of  the  skin  is  noted,  while  other  patients  suffer 
from  seborrhcea,  purpura,  or  herpes;  again,  when  lesions  of 
the  posterior  columns  of  the  cord  are  present,  perforating  ulcers 
are  apt  to  occur. 

The  arthropathies  are  not  uncommon  in  the  cases  in  which 
the  tabetic  symptoms  are  prominent,  and  even  spontaneous  frac- 
tures are  sometimes  met  with.  Among  the  trophic  disturbances 
which  play  an  important  role  are  those  associated  with  decubi- 
tus. During  the  terminal  stage,  unless  the  patient  is  kept 
scrupulously  clean  and  the  skin  frequently  bathed  and  all  points 
of  continuous  pressure  are  relieved  as  frequently  as  possible, 
bed-sores  are  apt  to  develop  which  are  exceedingly  difficult  to 

™  E.  v.  Niessel :  Ueber  Stauungserscheinungen  im  Bereiche  der  Gesichts- 

venen  bei  der  progressiven  Paralyse.     Berl.  klin.  Wchnschr.,  1902,  Nr.  35. 

27  Robertson,  Ford :    Pathology  of  Mental  Diseases.     Edinburgh,  1900. 


436 


PSYCHIATRY 


treat  and  may  eventually  prove  the  starting-points  of  a  general 
infection.  Some  patients  are  annoyed  by  a  profuse  flow  of 
saliva.28 

Febrile  disturbances  are  of  common  occurrence,  and  prac- 
tically a  case  never  comes  under  observation  in  which  at  some 
time  during  the  course  of  the  disease,  particularly  in  the  ter- 
minal stage,  abnormal  temperatures  are  not  noted.  Slight 
daily  variations  are  found  even  when  no  marked  complication 
exists.  The  curve  is  generally  irregular  and  the  rises  may  or 
may  not  be  associated  with  an  exacerbation  of  the  gastro- 
intestinal disturbances,  constipation,  retention  of  urine,  or  some 
lesion  in  the  respiratory  tract.  Furthermore,  it  is  probable  that 
febrile  movements  are  sometimes  due  to  central  lesions.  As  a 
rule,  there  is  a  marked  rise  (to  40 °  C.  or  over)  accompanying 
the  so-called  paretic  attacks.  Subnormal  temperatures  are 
sometimes  noted,  particularly  in  the  terminal  stage,  and  are  not 
infrequently  associated  with  symptoms  of  collapse. 

Vagaries  in  the  action  of  the  heart  are  frequently  noted. 
The  rhythm  is  sometimes  irregular,  the  rate  is  usually  increased, 
but  when  a  meningitis  exists  or  the  paretic  process  progresses 
towards  the  lower  centres  (vagus)  there  may  be  a  marked 
bradycardia.  The  vascular  disturbances  frequently  give  rise  to 
secondary  disturbances  in  the  action  of  the  heart.  In  the  periods 
of  depression,  as  a  rule,  there  is  a  rise  in  the  arterial  tension, 
whereas  during  the  excitement  a  fall  may  or  may  not  be  noted. 
The  respiratory  changes,  unless  they  are  the  result  of  complica- 
tions, are  purely  of  a  functional  nature.  On  account  of  their 
lowered  resistance  such  patients  are  particularly  liable  to  bron- 
chitis and  pneumonia,  or  even  pulmonary  abscess. 

The  general  nutrition  of  the  paretic,  as  a  rule,  suffers,  the 
deterioration  becoming  more  noticeable  with  the  greater  acute- 
ness  of  the  symptoms.  In  the  galloping  cases,  as  a  rule,  the 
weight  drops  and  remains  low,  the  patient  sometimes  losing  ten, 
fifteen,  or  even  twenty  pounds  in  a  few  weeks.     In  the  more 

28  Marandon  de  Montyel :    Contribution  a  l'etude  de  la  sialorrhee  dans 
la  paralysie  generale.     Gazette  des  hopitaux,  1902,  pp.  1087  et  1095. 


DEMENTIA    PARALYTICA 


437 


chronic  forms  of  the  disease,  especially  when  the  patient  is  under 
proper  treatment  in  a  hospital,  the  apparent  subsidence  of  the 
acute  symptoms  is  generally  associated  with  a  gain  in  the  bodily 
weight.  The  disturbances  in  the  function  of  the  liver  are  various. 
It  is  not  rare  to  find  an  increase  in  the  hepatic  dulness.  The  se- 
cretory functions  of  the  stomach,  as  a  rule,  are  materially  al- 
tered. There  is  sometimes  a  diminution  in  the  hydrochloric  acid 
or  even  a  complete  achlorhydria.  Constipation  often  alternates 
with  severe  attacks  of  diarrhcea.  As  would  be  expected  from 
the  pathological  changes,  the  urine  is  seldom  normal  and  in  the 
majority  of  cases  shows  more  or  less  marked  anomalies.  Prob- 
ably the  most  common  of  these  is  an  intermittent  albuminuria 
with  or  without  the  presence  of  hyaline  casts.  Peptonuria  is 
said  to  be  more  frequent  in  this  than  in  any  other  form  of 
alienation.  The  quantity  of  these  abnormal  constituents  is 
likely  to  reach  its  highest  point  during  the  attacks  of  excitement. 
Acetonuria  and  glycosuria  are  often  noted,  and,  as  has  already 
been  pointed  out,  the  appearance  of  these  constituents  in  some 
cases  seems  to  bear  a  close  relationship  to  the  symptoms 
(pseudo-paresis  of  diabetic  origin).  Polyuria  is  sometimes 
noted,  particularly  in  the  early  stages  of  the  disease. 

The  course  of  the  disease  may  be  broadly  divided  into 
three  periods;  (i)  the  prodromal  (stadium  prodromorum)  ; 
(2)  the  second,  in  which  the  mental  and  physical  symptoms 
become  fully  developed  (stadium  conclamatum)  ;  and  (3)  the 
terminal  stage,  during  which  the  dementia  becomes  more 
marked  and  finally  terminates  in  death  (stadium  terminale). 

The  first  period  may  extend  over  a  number  of  years,  and 
in  many  cases  the  earliest  symptoms  cannot  be  distinguished 
definitely  from  those  of  neurasthenia  or  the  psychasthenic 
states.29  In  this  first  period,  except  in  the  acute  cases,  the 
disease  is  almost  always  slowly  progressive,  and  the  neuras- 
thenic manifestations,  when  not  associated  with  the  specific 
mental  anomalies  or  the  bodily  symptoms  to  which  reference 

29  Schaffer,  Karl :  Anatomisch-klinische  Vortrage  aus  dem  Gebiete 
der  Nervenpathologie.  Jena,  1901.  Zehner :  Vortrag  iiber  cerebrale 
Neurasthenie  und  deren  Verhaltniss  zur  progressiven  Paralyse,  S.  259. 


438  PSYCHIATRY 

has  been  made,  can  only  be  distinguished  from  those  of  a 
true  nervous  exhaustion  or  psychasthenia  by  this  steadily  pro- 
gressive tendency.  The  recognition  of  the  paresis  is  even 
more  difficult  in  this  early  stage  in  individuals  who  would 
naturally  be  classed  among  the  so-called  degenerative  neur- 
asthenics, in  whom  there  is  a  marked  family  predisposition 
towards  nervous  and  mental  disease  and  who  all  their  lives  have 
been  nervous  and  subject  to  various  psychasthenic  manifesta- 
tions, such  as  defects  in  the  intellectual  and  moral  spheres,  and 
who  may  or  may  not  have  presented  a  variety  of  episodic 
symptoms. 

In  the  second  period  the  mental  and  physical  symptoms 
already  described  become  more  prominently  developed,  while 
in  the  final  stage  the  dementia  attains  its  maximum  develop- 
ment, the  physical  symptoms  are  greatly  accentuated,  and  some 
intercurrent  trouble  generally  hastens  death. 

The  different  clinical  forms  of  the  disease  may  con- 
veniently be  described  under  five  heads  :  ( i )  the  acute  or  so- 
called  galloping  paresis — forme  fondroyante;  (2)  the  de- 
pressed or  melancholic  type;  (3)  the  expansive  or  classical 
type;    (4)  the  simple  dementing  form;    (5)  the  atypical  cases. 

Acute  or  Galloping  Paresis,  Forme  Foudroyante. — Con- 
siderable confusion  exists  in  regard  to  the  propriety  of  in- 
cluding certain  cases  under  this  category.  As  long  ago  as  1852 
Beau  30  described  a  series  of  cases  which  were  characterized  by 
febrile  symptoms,  incoordination  of  movements,  and  various 
forms  of  delirium,  ending  in  death  within  two  or  three  weeks 
after  the  onset.  A  majority,  if  not  all,  of  these  cases  not  im- 
probably belong  in  the  category  of  the  acute  deliria.  Forms, 
however,  certainly  occur  which  run  their  course  in  from  six  to 
twelve  months  and  on  post-mortem  examination  reveal  a  series 
of  changes  identical  with  those  described  as  characteristic  of 
general  paresis.  As  Buchholtz  31  has  shown,  we  must  exclude 
from  this  group  such  cases  as  begin  with  a  slowly  progressive 


1  Paralyse  generale  aigiie.    Archives  generales  de  medecine,  1852. 
Arch.  f.  Psych,  u.  Nervenkrankh.,  Bd.  xxxvi,  H.  2. 


DEMENTIA    PARALYTICA  439 

prodromal  period  culminating  in  an  acute  outbreak  with  a  fatal 
termination.  Furthermore,  there  must  be  excluded  from  this 
group  of  cases  those  which  begin  with  acute  symptoms  but  are 
complicated  by  some  intercurrent  trouble,  such  as  tuberculosis, 
sepsis,  etc.,  not  the  immediate  result  of  the  disease  process. 
Some  observers  would  have  this  category  still  further  restricted 
to  those  cases  which  terminate  rapidly  in  death  after  delirious 
or  coma-like  states  with  severe  seizures,  the  result  of  an  exhaus- 
tion of  the  nerve-centres  (Heilbronner).  Weber32  maintains 
that  the  group  of  symptoms  frequently  described  as  occurring 
only  in  galloping  paresis  is  not  above  suspicion,  as  the  proof  has 
not  yet  been  given  that  this  particular  symptom-complex  is 
specific  for  the  disease,  and,  further,  that  the  clinical  picture 
drawn  by  Buchholz  by  no  means  forms  an  entity,  but  rather 
represents  an  accident  determined  by  secondary  factors,  such  as 
the  anatomical  localization  of  the  disease  process  in  certain 
areas,  accidental  injuries,  the  result  of  faulty  nutrition,  exhaus- 
tion, and  so  on. 

There  is,  however,  a  class  of  cases  that  begin  with  a  very 
acute  onset.  The  patient  may  for  several  days  or  one  or  two 
weeks  have  shown  signs  of  nervousness,  irritability,  depression, 
slight  excitement,  insomnia,  and  loss  of  appetite,  but  none  of  the 
physical  symptoms  characteristic  of  paresis  need  be  present. 
Then  suddenly  an  acute  outbreak  occurs  characterized  by 
marked  disturbance  in  orientation,  a  tendency  to  confuse  the 
identity  of  friends  and  members  of  the  family,  these  manifesta- 
tions being  sometimes  accompanied  by  exhilaration  or  exalta- 
tion which  may  or  may  not  progress  to  a  marked  megalomania. 
Generally  such  patients  are  very  excited,  aggressive ;  they  lose 
all  sense  of  decency,  are  overwhelmed  by  hallucinations  both 
auditory  and  visual,  which  for  a  time  seem  to  dominate  their 
actions.  During  these  periods  of  excitement  these  individuals 
are  exceedingly  dangerous,  not  only  to  themselves,  but  also  to 
those  about  them.     The  emotional  instability  is   often  quite 

32  Ueber  die  galoppierende  Paralyse  nebst  einigen  Bemerkungen  iiber 
Symptomatologie  und  pathologische  Anatomie  dieser  Erkrankung.  Mo- 
natsschr.  f.  Psych,  u.  Neurol.,  Bd.  xiv,  November,  1903,  H.  5,  S.  374. 


44Q 


PSYCHIATRY 


marked.  For  a  short  time  the  patient  is  hilarious  and  excited, 
or,  again,  there  may  be  intervals  of  depression  and  weakness. 
In  the  earlier  stage  of  the  delirium  the  physical  symptoms  of 
paresis  may  be  practically  absent,  but  gradually  the  somatic 
changes  make  their  appearance.  There  is  generally  consider- 
able difficulty  in  making  the  proper  tests,  but  when  this  is  pos- 
sible it  is  often  found  that  the  consensual  reflex  is  becoming  less 
and  less  active  for  light.  There  are  apt  to  be  slight  facial  in- 
equalities due  to  paresis  of  the  nerve  and  mild  disturbances  of 
speech.  As  a  rule,  the  incoordination  of  movements  becomes 
marked  and  may  develop  into  a  pronounced  ataxia.  Weygandt 
affirms  that  the  bodily  symptoms  develop  rapidly,  and  always 
keep  pace  with  the  mental  deterioration,  but  our  own  experience 
has  by  no  means  confirmed  this  view.  At  times  the  excitement 
amounts  to  a  frenzy,  rivalling  that  of  the  epileptic  psychoses. 
If  left  to  themselves,  the  patients  rush  up  and  down  the  room, 
gesticulating  and  threatening  attendants  and  physicians  with 
vengeance;  they  refuse  food  and  will  not  allow  themselves  to 
be  touched.  Occasionally  the  mental  symptoms  may  on  super- 
ficial examination  resemble  those  of  manic-depressive  insanity, 
but  the  apparent  flight  of  ideas  in  which  sound  association  and 
alliterations  predominate  is  in  reality  not  so  marked  as  in  the 
latter  class  of  cases.  The  distractibility  of  such  patients  is 
pronounced.  Each  new  stimulus,  as  it  impinges  upon  the  cere- 
bral cortex,  produces  an  immediate  reaction  at  once  reflected  in 
the  speech  or  action. 

Remissions  are  not  infrequent,  and  the  greatest  excitement, 
associated  with  an  hallucinatory  mania,  incoherence,  and  me- 
galomania, may  alternate  with  periods  of  calm  characterized  by 
a  remarkable  disappearance  of  both  mental  and  physical  symp- 
toms. If  death  does  not  follow  as  the  result  of  some  accident 
or  intercurrent  trouble,  such  as  pneumonia,  infection,  Bright's 
disease,  etc.,  the  patient  may  sink  rapidly  during  one  of  the 
periods  of  excitement  from  pure  exhaustion.  The  history  of 
the  following  case  illustrates  this  type  of  the  disease : 

Male,  aged  37,  married.    Admitted  to  the  Sheppard  and  Enoch  Pratt 
Hospital  October  29,  1901.    Died  March  2,  1902. 


DEMENTIA    PARALYTICA  441 

Family  History. — Negative. 

Personal  History. — No  history  of  severe  illness.  No  previous  aliena- 
tion. History  of  probable  luetic  infection  several  years  ago,  for  which  he 
was  treated. 

Present  Illness. — During  September,  1901,  patient  began  to  lose  interest 
in  his  work.  He  became  quite  nervous  and  worried  about  his  work  and 
complained  of  digestive  disturbances,  for  which  he  consulted  a  physician. 
Two  weeks  prior  to  his  admission  to  the  hospital  he  stopped  work,  became 
markedly  apathetic,  and  at  times  hypochondriacal.  Marked  insomnia  de- 
veloped and  vague  suspicions.  He  feared  that  persons  were  coming  into 
the  house  at  night  and  was  also  troubled  with  auditory  hallucinations. 

Examination  in  Hospital,  October  30. — Lying  in  bed,  apparently  com- 
fortable; takes  no  notice  of  persons  entering  the  room;  gives  name  cor- 
rectly and  year  of  his  birth,  although  unable  to  give  his  age  in  years.  Has 
slight  subjective  appreciation  of  defect  in  memory.  When  he  tries  to 
speak  his  tongue  becomes  tremulous  and  immovable,  as  if  the  muscles  were 
easily  fatigued.  At  times  the  deeper  muscles  are  thrown  into  play  and 
the  lower  jaw  is  frequently  moved  to  the  right.  The  lips  are  puckered 
and  the  words  come  with  an  explosive  force.  There  is  some  slight  slurring 
and  a  tendency  to  drop  syllables,  but  the  defect  is  not  sufficiently  marked 
to  be  regarded  as  characteristic  of  a  typical  case  of  paresis.  The  patient 
is  distractible  and  emotional.  He  talks  a  great  deal  about  having  con- 
tracted syphilis,  and  fears  that  he  has  given  the  disease  to  his  wife.  He 
has  marked  religious  fears  and  is  anxious  to  know  whether  he  can  be 
saved.  He  occasionally  complains  of  hearing  voices  which  tell  him  disa- 
greeable things.  There  is  marked  incoherence.  At  times  he  is  slightly  im- 
pulsive, springing  up  in  bed  and  pointing  to  the  electric  light  fixtures, 
which  he  wishes  to  have  removed.  Once  during  the  examination  he 
jumped  up  in  bed,  threw  off  the  coverings,  and  went  through  the  motions 
of  taking  a  bath.  When  he  became  quiet  he  did  not  seem  to  remember 
what  he  had  done.  He  would  give  no  reason  for  his  actions  except  once 
to  say  "  It's  putrid." 

Physical  Examination. — Strong  frame,  poorly  nourished.  Takes  an 
occasional  interest  in  what  is  going  on  about  him  and  follows  the  move- 
ments of  persons  in  the  room.  The  pupils  are  equal,  dilated ;  direct  and 
consensual  reactions  for  light  normal ;  accommodation  also  normal.  Re- 
flexes :  Dermatographia  well  marked.  Abdominal  skin  reflexes  scarcely 
perceptible.  Cremasteric  reflexes  present  on  both  sides.  Muscles :  No 
apparent  insufficiency  in  the  eye  muscles.  No  nystagmus.  The  grip  of  the 
two  hands  is  markedly  different.  The  greater  force  at  first  is  in  the 
right  hand. 

Heart :  No  marked  enlargement.  Sounds  clear  at  apex.  Second 
sound  at  base  slightly  accentuated.  Arteries  slightly  sclerotic.  Inguinal 
glands  slightly  enlarged  on  either  side,  firm,  but  showing  no  shotty  con- 
sistence.    No  nodes  on  the  tibia. 

Urine :  800  cc.  in  24  hours.  Specific  gravity,  1025 ;  distinct  trace  of 
albumin,  urea  1.34,  indican  diminished.    No  casts. 

A  few  days  after  the  first  examination  the  patient  became  much  more 


442 


PSYCHIATRY 


restless  and  emotional.  The  distractibility  was  increased.  In  a  few  days 
the  incoordination  of  the  muscles  of  the  face,  eyes,  and  tongue  became 
much  more  marked.  The  speech  was  low  and  muttering.  When  his  arms 
were  held  out  the  involuntary  and  incoordinated  movements  became  much 
more  marked,  and  at  times  were  choreiform  in  character.  At  times  the 
patient  would  be  in  a  very  good  humor,  and  his  conversation  would 
become  slightly  more  connected  and  logical.  He  affirmed  that  he  loved 
every  one  and  wanted  to  be  loved  by  every  one.  He  claimed  to  have  made 
several  excursions  to  Heaven  and  described  meeting  persons  as  tall  as  the 
room.  Occasionally  he  had  attacks  in  which  the  motor  restlessness  and 
general  excitement  became  very  intense,  and  on  a  few  occasions  he  was 
aggressively  violent,  threatening  to  kill  any  one  who  came  near  him.  The 
speech  disturbances  became  more  marked.  The  condition  did  not  change 
materially  until.  February,  when  he  had  several  epileptiform  convulsions, 
accompanied  by  complete  loss  of  consciousness  and  general  sweating ;  the 
tongue  was  bloody  from  having  been  bitten,  and  the  respirations  were  shal- 
low. The  eyes,  as  a  rule,  were  fixed  towards  the  right  and  upward.  At 
times  there  was  a  slight  oscillation  of  the  eyeballs,  somewhat  rhythmic,  and 
suggesting  nystagmus.  Towards  the  middle  of  the  month  the  excitement 
became  more  intense  and  his  ideas  and  delusions  first  became  definitely 
expansive.  At  the  end  of  the  month  the  patient  became  distinctly  worse 
and  very  drowsy.  There  was  no  evidence  of  any  pulmonary  lesion.  The 
heart  sounds  were  rapid,  the  first  impure  at  the  apex.  The  urine  showed 
a  few  casts,  but  no  blood.  The  patient  sank  rapidly  and  died  March  2, 
1902. 

The  pathological  findings  have  been  described  at  length,33  and  it  is 
not  necessary  to  repeat  them  here  except  to  say  that  they  were  all  indicative 
of  general  paresis. 

The  Depressed  Type. — This  form  is  not  infrequent, 
although  the  exact  proportion  can  not  be  accurately  expressed  in 
figures.  In  Europe  competent  observers  affirm  that  it  includes 
from  a  fourth  to  a  third  of  all  the  cases  of  general  paresis ;  as 
a  rule,  it  is  characterized  by  few  remissions  and  terminates 
fatally  in  from  two  to  three  years.  In  the  prodromal  period  we 
meet  with  a  variety  of  psychasthenic  symptoms.  Gradually 
hypochondriacal  ideas  begin  to  make  their  appearance,  the 
patient's  insight  into  his  own  condition  being  usually  retained 
longer  than  in  the  other  forms  of  the  disease.  Such  individuals 
not   infrequently   complain   that   "something   is   wrong  with 

33  Paton,  Stewart,  and  G.  Y.  Rusk :  Acute  Paresis,  with  Report  of  a 
Case ;  the  Clinical  History  and  Pathological  Findings.  Am.  Journ.  Insan., 
1903,  vol.  lix,  No.  3. 


DEMENTIA    PARALYTICA 


443 


them ;"  they  are  conscious  of  defects  in  memory  and  begin  to  feel 
that  they  can  not  trust  themselves  in  the  performance  of  their 
ordinary  routine  duties.  They  notice  their  inability  to  focus  the 
attention,  to  make  any  prolonged  mental  or  physical  effort,  and 
not  infrequently  affirm  that  they  are  going  to  lose  their  minds ; 
that  there  is  no  hope  for  their  recovery.  At  times  they  suffer 
from  severe  attacks  of  migraine,  or  again  they  may  be  subject 
to  headaches  so  persistent  and  of  such  a  localized  character  as 
to  suggest  the  existence  of  a  neoplasm.  As  a  rule,  such  patients, 
particularly  in  the  earlier  stages,  are  very  irritable.  This  affec- 
tive state  becomes  the  more  noticeable  if  the  genuineness  of 
their  complaints  is  for  a  moment  called  into  question.  Not  in- 
frequently the  depression  is  interrupted  by  intervals  of  appre- 
hensiveness  and  anxiety  during  which  the  motor  restlessness 
increases  and  the  patient  becomes  greatly  excited.  Frequently 
insane  ideas  characterized  by  marked  oddities  and  absurdities 
make  their  appearance.  These  are  liable  to  become  even  more 
persistent  when  the  disease  reaches  the  highest  stage  of  its  de- 
velopment. The  patients  hear  voices,  sometimes  referred  to  the 
chest,  abdomen,  or  to  other  parts  of  the  body ;  or,  again,  they 
are  projected  and  seem  to  come  from  various  corners  of  the 
room,  from  under  the  bed,  or  from  outside  of  the  windows. 
Occasionally  the  voices  are  far  away,  lack  subjectivity,  and  have 
some  of  the  characteristics  of  psychic  hallucinations.  As  a  rule, 
they  say  unpleasant  or  obscene  things,  scold,  threaten,  or  terrify. 
The  specific  character  of  the  hallucinations  reveals  an  existing 
dementia.  Now  and  again  the  patient  may  apparently  be  con- 
vinced of  their  subjectivity  for  a  time,  but  in  the  great  majority 
of  cases  the  power  of  recognition  is  entirely  lost.  Sometimes 
patients  will  sit  and  indulge  in  a  monotonous,  uninterrupted 
wail,  lamenting  their  condition  or  their  inability  to  comply  with 
the  demands  made  by  the  voices.  As  a  rule,  the  visual  hallucina- 
tions are  less  dominating  and  less  insistent  than  the  auditory 
forms,  and  occasionally  are  associated  with  definite  individuals. 
The  haptic  forms  are  not  infrequent  and  are  usually  associated 
by  the  patient  with  external  agencies.  Spells  are  supposed  to  be 
thrown  over  them,  and  the  tingling  in  their  extremities  to  which 


444 


PSYCHIATRY 


they  are  subject  becomes  in  their  eyes  a  sign  that  they  have  been 
poisoned  by  unseen  powers.  All  the  devils  in  Hell  are  con- 
spiring to  make  them  unhappy  and  kill  them  by  slow  torture. 
The  incongruity  displayed  by  the  patients  is  sometimes  remark- 
able. An  individual  who  affirms  that  he  is  Prince  Louis  of  the 
Pole  Star  and  for  hundreds  of  years  has  been  flying  from  one 
world  to  the  other,  the  possessor  of  universal  power,  in  the  next 
breath  will  admit  that  he  is  kept  a  prisoner  in  the  hospital  and 
is  unable  to  get  away.  Although  true  remissions  in  this  form 
are  infrequent,  exacerbations  are  not  uncommon,  at  times  cul- 
minating in  a  period  of  hallucinatory  mania,  during 'which  the 
patients  become  very  violent  and  need  to  be  most  carefully 
guarded. 

Although  these  acute  exacerbations  with  the  intensification 
of  the  hallucinations  are  more  liable  to  occur  in  patients  who 
have  a  marked  alcoholic  history,  they  sometimes  are  met  with 
in  those  who  have  always  been  temperate.  The  danger  from 
such  patients  is  greatly  increased  when  the  ideas  of  persecu- 
tion become  prominent  and  render  them  suspicious  of  all  about 
them.  The  physician  and  nurses  become  spies,  the  hospital  is  a 
prison  or  a  Hell,  the  food  is  poisoned,  their  sickness  is  a  result 
of  a  conspiracy.  Every  sound  is  misinterpreted  and  becomes 
a  sign  of  some  one  approaching  with  some  sinister  motive  or 
bent  on  disturbing  their  peace.  Even  when  these  insane  ideas 
are  at  their  height  evidences  of  dementia  are  nearly  always 
present,  and  on  account  of  the  existing  distractibility  the  patient 
may  be  temporarily  diverted.  Although  many  of  the  cases  on 
superficial  examination  may  resemble  paranoiic  states,  such  indi- 
viduals seldom  refuse  to  eat,  and  if  tactfully  handled,  can,  as  a 
rule,  be  persuaded  to  do  as  the  nurse  desires,  except,  of  course, 
during  the  period  of  greatest  excitement.  Occasionally  the 
patient  passes  from  the  depression  into  a  period  of  stupor, 
which,  however,  can  not  be  regarded  in  the  light  of  a  remission. 
Personally  I  have  never  observed  a  case  in  which  a  genuine 
remission  occurred.  This  form  seems  to  be  relatively  more 
frequent  in  women  than  in  men,  and  on  account  of  its  com- 
paratively short  duration  it  may  be  classed  next  to  the  galloping 


DEMENTIA    PARALYTICA  445 

cases  as  the  most  severe  type  of  the  disease.  Such  patients  are 
particularly  difficult  to  nurse  on  account  of  their  suicidal  ten- 
dencies, and  if  not  restrained  frequently  resort  to  violence  upon 
others  in  order  to  accomplish  their  end.  If  no  intercurrent 
complication  develops,  they  die  as  a  result  of  exhaustion. 

The  Expansive  Form. — Until  recently  this  was  supposed 
to  include  the  majority  of  all  cases,  and  on  that  account  was 
regarded  as  the  classical  type  of  the  disease.  It  is  now  known, 
however,  that  the  percentage  of  the  expansive  forms  is  much 
smaller  than  that  representing  the  depressed  type,  only  about 
from  one-tenth  to  one-fifth  of  all  the  cases  coming  under  obser- 
vation belonging  to  the  former  category.  After  the  prodromal 
period  the  course  may  not  differ  essentially  from  that  observed 
in  other  types  of  the  disease.  The  patient  gradually  begins  to 
lose  an  insight  into  his  own  condition.  Although  at  first  he 
may  have  been  somewhat  hypochondriacal  and  conscious  of  his 
mental  and  physical  defects,  he  now  becomes  more  or  less  in- 
different or  apathetic.  It  is  worth  remembering  that  in  an  indi- 
vidual who  belongs  to  the  lower  classes  of  society  this  change 
may  on  casual  examination  be  mistaken  for  actual  improvement 
instead  of  a  deeper  clouding  of  the  intellect.  Formerly  de- 
pressed, the  patient  now  ceases  to  be  hypochondriacal  and 
often  appears  to  be  in  the  best  of  humors.  He  is  readily  elated. 
The  attacks  of  mild  apprehensiveness,  as  a  rule,  give  way  to 
states  of  exhilaration,  during  which  the  sense  of  well-being  is 
more  or  less  exaggerated.  The  patient  forgets  all  his  ailments, 
no  longer  complains  of  headache.  If  he  refers  at  all  to.  his  own 
case,  it  is  in  a  spirit  of  the  utmost  hopefulness,  and  he  affirms 
that  members  of  his  family  or  his  physician  exaggerate  his 
symptoms.  There  is  no  reason,  he  maintains,  why  he  can  not 
return  to  business  and  the  ordinary  routine  of  life.  Gradually 
the  self-confidence  increases  until  the  word  failure  is  left  out  of 
his  lexicon.  The  business  man  becomes  so  elated  that  he  is 
ready  and  willing  to  plunge  into  any  new  undertaking,  to  de- 
velop his  business  along  new  lines ;  he  becomes  restless  unless 
there  are  numerous  channels  for  the  discharge  of  his  surplus 
activity.    Any  rebuff  that  is  met  with  is  either  viewed  in  a  spirit 


446  PSYCHIATRY 

of  utter  indifference  or  only  serves  to  intensify  his  self-com- 
placency. The  sober-minded,  phlegmatic  individual  is  puffed 
up  with  his  own  conceit,  becomes  a  braggart,  his  speech  is  de- 
cidedly bombastic.  The  affective  state  is  usually  one  of  jubi- 
lance or  undue  elation.  The  speech  is  characterized  by  extrava- 
gance, and  the  individual  exhibits  many  eccentricities  of 
character  that  are  absolutely  foreign  to  him. 

The  changes  in  the  organic  sensations  produce  an  entire 
absence  of  fatigue.  Such  individuals  are  always  ready  for  any 
new  undertaking  and  delight  in  the  opportunity  to  show  their 
supposed  mental  and  physical  superiority.  Gradually  the  sense 
of  personal  vanity  increases  until  it  knows  no  bounds  and  is 
beyond  competition.  The  exuberance  of  spirit  is  often  shown 
by  the  actions — singing,  laughing,  or  dancing.  The  motor  rest- 
lessness increases,  and  with  it,  as  a  rule,  there  is  an  exaggera- 
tion of  the  tremor,  of  the  incoordination,  and  clumsiness  of 
movement.  The  patient  displays  a  still  more  boisterous  ag- 
gressiveness and  is  continually  referring  to  his  deeds  of  prowess 
or  harping  upon  his  supposed  physical  superiority.  The  insane 
ideas  are  fanciful,  extremely  grotesque,  at  times  obscene.  Not 
infrequently  the  delusions  are  colored  by  memories  of  the  daily 
occupation  of  the  individual  prior  to  the  onset  of  the  illness. 
The  business  man  is  occupied  in  devising  schemes  to  extend  his 
business,  in  making  long  journeys.  The  professional  man  is 
busy  in  his  profession.  As  the  dementia  develops  the  extrava- 
gance of  these  ideas  increases  rapidly.  Such  individuals  do  not 
confine  their  plans  and  schemes  to  this  world,  but  often  would 
have  them  embrace  Heaven,  Hell,  and  the  whole  universe. 
Nothing  can  exceed  in  extravagance  the  ideas  entertained  by 
these  patients  when  the  megalomania  is  at  its  height.  As  the 
disease  progresses,  the  defects  in  intelligence  become  more  and 
more  marked,  and  at  times  periods  of  great  excitement  may 
intervene,  during  which  the  patients  are  liable  to  tear  their 
clothes  or  inflict  severe  injuries  upon  themselves  unless  closely 
watched.  The  times  of  excitement  sometimes  give  way  to 
periods  of  depression  and  the  disorder  may  take  on  a  circular 
form.     As  may  be  inferred,  time  and  space  orientation  are 


DEMENTIA    PARALYTICA  447 

seriously  disturbed.  The  patients  seem  to  retain  only  in  a 
vague  way  any  appreciation  of  their  surroundings.  They  are 
so  self-centred  in  their  own  delusions  that  they  are  absolutely 
indifferent  to  the  interests  of  those  about  them.  The  emotional 
reactions  correspond  with  the  ideas  in  consciousness.  The  sense 
of  power,  of  well-being,  is  reflected  in  all  that  the  patient  does 
and  says. 

As  a  rule,  the  course  of  these  cases  is  somewhat  longer  than 
that  belonging  to  the  depressed  types.  Not  infrequently  in 
institutions  these  patients  live  for  quite  a  long  while — as  much 
as  eight  or  ten  years,  and  some  observers  have  reported  cases 
of  much  longer  duration.  There  are  decided  remissions,  and 
although  these  individuals  still  refer  to  their  insane  ideas  and 
delusions,  the  intensity  of  these  is  diminished  and  does  not  seem 
to  dominate  the  patients  unless  they  are  provoked  or  unduly 
disturbed.  This  form  of  the  disease  seems  to  be  less  frequent 
in  women  than  in  men.  Competent  observers  have  concluded 
that  this  type  is  much  rarer  now  than  it  was  twenty  years  ago, 
but  the  question  is  one  that  is  exceedingly  difficult  to  determine, 
inasmuch  as  many  of  the  cases  which  are  now  recognized  as 
instances  of  general  paresis  at  that  time  were  classed  in  other 
categories.  No  form  was  included  unless  it  was  characterized 
by  grandiose  ideas  and  exhilaration.  The  recognition  of  so 
many  of  the  other  forms  of  the  disease  would,  therefore,  have  a 
tendency  to  make  the  expansive  type  appear  relatively  less 
frequent. 

A  transition  from  the  second  to  the  terminal  stage  of  the 
disease  is  more  gradual,  as  a  rule,  than  in  the  depressed  form, 
and  it  is  frequently  impossible  to  sharply  differentiate  these  two 
epochs.  As  in  the  other  forms,  the  patient  may  succumb  to 
various  complications.  During  periods  of  remission  it  not  in- 
frequently happens  that  the  physical  condition  improves  very 
markedly  and  some  patients  increase  quite  rapidly  in  weight. 

As  a  rule,  the  hallucinations  in  this  form  do  not  play  a  very 
important  role.  The  auditory  are  more  apt  to  occur  than  are 
the  visual  forms,  but  these  hallucinatory  states  are  somewhat 
rare,  and  when  they  occur  are  apt  to  be  only  transitory. 


448  PSYCHIATRY 

The  Dementing  Form. — According  to  some  observers  the 
so-called  dementing  type  of  paresis  is  becoming  more  frequent. 
This  view,  however,  needs  further  confirmation,  and  it  can 
readily  be  conceived  that  the  apparent  increase  in  frequency  is 
due  to  the  fact  that  these  cases,  which  were  formerly  overlooked 
and  classed  among  the  various  forms  of  dementia,  are  now 
recognized  as  instances  of  dementia  paralytica.  Indifference 
and  apathy  are  the  chief  characteristics  of  individuals  afflicted 
by  this  form  of  the  disease.  In  the  prodromal  period  we  may 
meet  with  periods  of  depression,  but  gradually  the  affective  state 
is  replaced  by  one  of  apathy.  At  first  the  patients  show  a  dis- 
inclination to  work  or  to  exert  themselves,  and  although  for  a 
time  retaining  some  appreciation  of  their  condition,  gradually 
lose  it  entirely.  They  sit  about  the  house,  taking  but  little  in- 
terest in  anything  that  goes  on  about  them ;  they  neglect  their 
work,  their  families,  and  become  utterly  devoid  of  any  sense  of 
duty.  When  asked  to  explain  their  apathy  they  may  make  a 
feeble  attempt  to  do  so,  but,  as  a  rule,  are  unable  to  offer  a  sat- 
isfactory explanation  for  their  conduct.  The  hypochondriacal 
complaints  which  have  been  more  or  less  pronounced  in  the 
prodromal  period  disappear.  The  patients,  when  spoken  to, 
reply  in  rather  a  low,  monotonous  voice,  not  infrequently  in 
monosyllables,  and  are  unable  to  give  any  satisfactory  account 
of  themselves  or  the  onset  of  their  disease. 

The  lapses  in  attention  are  more  passive  than  active.  The 
distractibility  is  not  excessive ;  the  instant  the  patient  is  left  to 
himself  he  immediately  lapses  into  this  apathetic  condition.  As 
a  rule,  the  impairment  of  the  general  sensibility  seems  to  be 
more  marked  than  in  the  other  types  of  the  disease.  The  patient 
can  be  pricked  with  a  needle,  pinched,  or  made  to  suffer  quite  a 
severe  injury  without  any  corresponding  emotional  reaction. 
As  the  disease  progresses  the  apathy  becomes  more  and  more 
profound  and  may,  as  a  rule,  be  easily  distinguished  from  that 
characterizing  the  other  forms  of  dementia.  The  primary  sen- 
sations are  apt  to  be  greatly  impaired,  and  it  is  almost  impos- 
sible to  stimulate  the  patient  sufficiently  to  evoke  an  emotional 
reaction  of  any  degree  of  intensity. 


DEMENTIA    PARALYTICA 


449 


Atypical  Cases. — In  this  category  are  included  a  variety 
of  cases  which  run  an  atypical  course,  at  least  10  or  15  per 
cent,  of  all  the  various  forms,  (a)  Among-  the  more  common 
are  those  occurring  in  individuals  at  a  more  advanced  period 
of  life  than  is  common  in  cases  of  dementia  paralytica.  In 
some  the  symptoms  are  largely  local — sensory  or  motor 
aphasia,  alexia,  agraphia,  hemianopsia,  and  loss  of  certain  cor- 
tical functions.  The  general  dementia  becomes  noticeable  only 
in  the  later  stages.  In  others  the  course  as  well  as  the  ana- 
tomical changes  are  of  such  a  nature  that  it  is  impossible  to 
differentiate  this  type  of  the  disease  from  a  senile  dementia 
(Lissauer).  (b)  Among  the  atypical  cases  those  in  which  the 
spinal  lesions  play  an  important  role  are  not  infrequent  and 
include  the  tabetic,  amyotrophic,  and  spastic  forms.  In  addi- 
tion to  the  mental  symptoms  of  paresis,  such  as  have  already 
been  described,  we  have  those  of  the  complicating  cord  lesions ; 
but  for  a  detailed  description  of  these  the  reader  is  referred  to 
the  various  text-books  on  neurology. 

The  course  of  the  so-called  tabo-paresis,  occurring  in  only 
about  6  per  cent,  of  the  cases,  in  certain  particulars  is  essentially 
different  from  that  of  the  other  types  of  the  malady.34  Lues 
seems  to  be  even  a  more  important  etiological  factor  in  these 
than  in  other  forms.  Optic  atrophy,  paralysis  of  the  external 
muscles  of  the  eye,  an  impaired  pain  sense,  relatively  little  dis- 
turbance in  speech,  severe  crises  with  marked  disturbances  of 
the  bladder  and  rectum  and  prolonged  remissions  are,  as  a  rule, 
the  most  pronounced  features  in  the  clinical  picture.  Occa- 
sionally in  such  cases  we  meet  with  peculiar  delirious  states 
with  vivid  and  varied  hallucinations.  The  pathological  lesions 
in  the  cord  are  closely  akin  to,  if  not  identical  with,  the  pure 
degenerative  sclerosis  of  the  posterior  columns.  In  a  second 
division  the  lateral  columns  are  also  affected  and  give  rise  to 


**  Torkel,  K.  E.  F. :  Besteht  eine  gesetzmassige  Verschiedenheit  in 
Verlaufsart  und  Dauer  der  progressiven  Paralyse  je  nach  dem  Charakter 
der  begleitenden  Ruckenmarksaffection  ?  Psych.  Klinik  in  Marburg. 
Inaug.  Dissert.,  1903. 

29 


450 


PSYCHIATRY 


spastic  symptoms,  while  in  the  third  group  there  is  a  combina- 
tion of  both  forms  of  the  lesions. 

We  are  particularly  indebted  to  Dr.  H.  A.  Cotton  for  the 
following  note  on  the  much-mooted  point  as  to  the  relation  of 
tabes  and  paresis. 

Among  the  supporters  of  the  theory  of  the  identity  of  the  two  diseases 
may  be  mentioned  Raymond,  Nagotte,  Fournier,  Schaffer,  and  Mott,  who 
base  their  opinion  upon  the  following  facts:  (i)  That  tabes  complicates 
general  paresis  in  at  least  two-thirds  of  the  cases.  (2)  The  occurrence  of 
symptoms  in  both  diseases  which  show  both  as  to  their  onset  and  develop- 
ment a  marked  similarity.  (3)  The  identity  of  the  etiology.  (4)  A  simi- 
larity in  the  pathological  changes  although  a  different  anatomical  location. 
Those  who  are  opposed  to  this  doctrine,  Joffroy,  Ballet,  Fuerstner,  Nissl, 
and  others,  maintain  that  the  two  diseases  are  entirely  distinct  and  that 
when  they  are  associated  it  is  merely  a  coincidence.  The  tendency,  how- 
ever, of  the  two  processes  to  be  associated  in  the  same  subject  is  con- 
sidered by  some  to  be  an  important  point  in  favor  of  the  former  view. 
This  concurrence  may  occur  in  one  of  the  three  following  ways:  (1)  The 
initial  tabetic  symptoms  may  later  in  the  disease  be  complicated  by 
those  of  general  paresis;  or  (2)  the  converse  of  this  is  true;  (3)  the 
two  disorders  appear  about  the  same  time  and  run  a  parallel  course.  Those 
who  from  a  pathological  basis  maintain  that  the  two  processes  are  not 
identical  affirm  that  general  paresis  is  a  chronic  inflammatory  process  and 
tabes  a  degenerative  one,  while  those  who  dissent  from  this  view  affirm 
that  in  cases  of  tabes  where  no  paretic  symptoms  were  noticed  during 
life,  after  death  the  lesions  characteristic  of  general  paresis  were  demon- 
strated in  the  brain ;  and,  furthermore,  that  in  cases  of  paresis  uncom- 
plicated by  tabetic  lesions  degenerations  were  found  at  autopsy  in  the 
posterior  columns.  The  question  needs  still  further  investigation  before 
a  definite  conclusion  can  be  reached. 

The  Cerebellar  Form. — Although  it  has  been  shown  by  a 
number  of  observers  that  the  cerebellum  is  regularly  affected  in 
a  large  majority  of  cases,  we  meet  with  a  very  small  number 
in  which  it  has  undergone  any  marked  degree  of  atrophy. 
Cases  have  been  described  in  which  the  diagnosis  of  cerebellar 
tumor  has  been  made.  As  a  rule,  later  in  the  disease  the  symp- 
toms of  general  paresis  develop  so  that  the  differentiation  be- 
comes possible.  Buder 35  has  described  a  case  of  general 
paralysis   in  which   the  physical   symptoms   were   an   Argyll- 

35  Buder :    Allg.  Ztschr.  f.  Psych.,  Bd.  lx,  H.  4. 


DEMENTIA    PARALYTICA 


451 


Robertson  pupil,  absence  of  knee-jerk,  fairly  characteristic 
speech  disturbance  and  a  hemiplegia,  and  associated  with  them 
considerable  dementia;  this  same  patient  was  also  subject  to 
apoplectiform  attacks.  At  autopsy  it  was  found  that  the  left 
hemisphere  was  32  per  cent,  lighter  in  weight  than  the  right 
( 154  grammes)  and  that  there  was  a  marked  cerebellar  atrophy 
on  the  opposite  side.  It  is  by  no  means  clear,  however,  that 
such  cases  are  not  to  be  regarded  as  instances  of  paresis  com- 
plicated by  localized  lesions  not  in  any  sense  immediately  re- 
lated to  the  case,  but  merely  accidental.  In  still  other  very 
rare  cases  the  degeneration  seems  to  be  more  or  less  confined 
to  the  thalamic  regions,  but  what  is  the  nature  of  the  symp- 
toms is  as  yet  only  very  imperfectly  understood.  Adolf  Meyer, 
among  others,  has  more  recently  called  attention  to  the  im- 
portance of  these  cases  in  which  the  atrophy  is  excessive  on 
one  side  of  the  brain  and  only  slight  on  the  other. 

Seizures. — These  are  frequently  the  result  of  cortical  irri- 
tation and  are  generally  described  as  apoplectiform  or  epilepti- 
form in  character.  They  may  or  may  not  be  accompanied  by  a 
rise  of  temperature.  As  a  rule,  the  changes  in  consciousness  vary 
from  a  slight  dulling  to  temporary  abolition.  In  the  latter  case 
the  patients  fail  to  react  to  any  form  of  external  stimulation,  but 
lie  in  a  stupor,  frequently  retaining  no  control  over  the  bladder 
or  rectum.  Necessarily  in  all  instances  speech  is  seriously  inter- 
fered with.  In  the  milder  attacks  the  patient  is  able  to  produce 
sounds,  occasionally  words,  while  in  the  severer  forms  with 
marked  loss  of  consciousness  there  is,  of  course,  no  attempt  at 
speech.  The  pulse  becomes  irregular  and  sometimes  dicrotic. 
As  a  rule,  there  is  considerable  difficulty  in  swallowing.  In  some 
cases  various  groups  of  muscles  are  affected  by  a  clonic  spasm, 
while  in  other  instances  there  are  varying  degrees  of  paresis  and 
occasionally  one  observes  in  the  non-paralyzed  group  of  muscles 
a  hypertonicity.  Sometimes  the  clonic  seizure  is  replaced  by  a 
tonic  convulsion.  Whenever  a  permanent  monoplegia  or  hemi- 
plegia develops  it  may  usually  be  considered  as  an  evidence  of 
the  existence  of  a  complication.  Not  infrequently  during  the 
attacks  the  eye-muscles,  particularly  those  supplied  by  the  third 


452 


PSYCHIATRY 


and  sixth  nerves,  are  very  apt  to  be  affected.  Nystagmus  may 
also  be  noted.  Prior  to  and  following-  the  attacks  one  not  infre- 
quently meets  with  the  so-called  trigeminus  symptom,  when  the 
patient  sits  and  grinds  his  teeth.  Frequently  there  is  a  marked 
difference  in  the  surface  temperature  between  the  paralyzed  and 
non-paralyzed  areas.  During  these  attacks  the  seizures  not 
infrequently  begin  with  an  epileptiform  attack,  the  patient 
suddenly  sinking  to  the  ground  and  losing  consciousness, 
after  which  the  symptoms  referred  to  above  develop.  The 
reflexes  are  wont  to  be  interfered  with,  being  sometimes  di- 
minished but  seldom  totally  absent  except  in  the  severest  cases. 
On  the  non-paralyzed  side  the  tendon  reflexes  are  often  in- 
creased. On  account  of  the  disturbance  in  consciousness  it 
is  impossible  to  test  the  touch  and  pain  sensation  with  any 
degree  of  accuracy.  As  a  rule,  the  primary  sensations  are 
seriously  interfered  wTith.  There  may  be  temporary  blindness 
or  deafness.  Not  infrequently  auditory  and  visual  hallucina- 
tions precede  the  attack.  When  the  motor  centres  are  in- 
volved there  is  motor  aphasia  and  in  other  cases  the  sensory 
aphasia  is  present.  The  duration  and  intensity  of  the  attacks 
vary  greatly.  In  some  cases  there  is  a  slight  vertigo  lasting  a 
few  seconds  with  temporary  interference  with  motility  and 
disturbance  of  speech;  in  others  there  are  severe  seizures 
which  last  for  two  or  three  days. 

Remissions. — During  the  course  of  the  disease,  particu- 
larly in  the  chronic  forms,  remissions  frequently  occur.  They 
are  chiefly  met  with  in  the  slowly  progressive  cases  which  begin 
with  tabetic  symptoms.  Some  well-authenticated  instances 
have  been  recorded  in  which  there  was  considerable  improve- 
ment in  the  disturbances  of  speech,  in  the  tremor,  in  the  gen- 
eral incoordination  of  muscular  movements  and  an  actual  sub- 
sidence of  the  mental  symptoms,  and  such  phases  may  extend 
over  long  periods  of  time.  For  example,  Schafer35  reports  a 
case  which  ran  a  course  of  twenty-three  years  and  was  charac- 


38  Schafer,  Gerhard :    Zur  Casuistik  der  progressiven  Paralyse.     Lange 
Dauer  und  erhebliche  Remission.    Ztschr.  f.  Psych.,  lx. 


DEMENTIA    PARALYTICA  453 

terized  by  the  remarkable  length  of  the  remission.  The  diag- 
nosis was  ultimately  verified  by  the  pathological  findings.  In 
another  case  reported  by  the  same  author  after  the  disease  had 
progressed  steadily  for  two  years  a  remission  almost  equal  to 
that  in  the  first  case  was  noted.  In  the  latter  instance  the 
patient  convalesced  so  far  as  to  be  able  to  take  up  again  his 
work  as  a  stenographer,  and  after  examination  by  the  military 
authorities  was  said  to  be  entirely  well.  It  is  not  at  all  im- 
probable that  the  remissions  are  much  more  apt  to  occur  in 
cases  which  come  under  treatment  early  in  the  disease  than  in 
those  who  only  come  to  the  hospital  after  the  symptoms  are 
well  developed.  The  remissions  in  the  acute  cases  are  only 
temporary,  while  in  the  expansive  and  dementing  forms  they 
are  much  more  apt  to  be  of  considerable  duration  than  in  the 
melancholic  cases. 

Termination. — In  spite  of  occasional  references  in  the  liter- 
ature to  a  favorable  outcome,  the  evidence  to  the  contrary  at 
present  is  so  convincing  that  it  may  be  taken  for  granted  that 
progressive  paralysis  always  terminates  fatally.  The  supposed 
cures  recorded  by  Schule,  Schafer,  Tuczek,  Svetlin,  on  account 
of  the  incompleteness  of  the  records,  cannot  with  certainty  be 
differentiated  from  instances  representing  certain  phases  of 
manic-depressive  insanity,  alcoholism,  catatonia,  or  hysterical 
degeneracy.  And  even  for  those  cases  in  which  the  disappear- 
ance of  all  the  symptoms  undoubtedly  occurred  we  unfor- 
tunately have  no  positive  proof  that  a  restitutio  ad  integrum  took 
place.  Thus  in  one  of  Alzheimer's  patients  who  died  from  an 
intercurrent  trouble  during  a  remission,  at  autopsy  the  changes 
characteristic  of  dementia  paralytica  were  demonstrable 
throughout  the  central  nervous  system.  Sufficient  has  already 
been  said  to  show  that  a  great  majority  of  the  patients  die  from 
some  complication,  as,  for  instance,  a  lobar  or  catarrhal  pneu- 
monia, or  an  infection,  such  as  cystitis  or  pyelonephritis,  or  from 
pure  exhaustion  generally  described  as  the  paretic  marasmus. 
The  course  of  the  disease  is  progressive  and  is  characterized 
by  the  fact  that  no  true — i.e.,  anatomical — remissions  actually 
occur,  and,  as  has  been  said,  even  where  all  the  symptoms  have 


454  PSYCHIATRY 

disappeared  the  contention  that  all  the  histological .  changes  in 
the  central  nervous  system  have  been  obliterated  so  that  the 
nervous  and  other  elements  are  restored  to  their  normal  con- 
dition is  not  capable  of  demonstration,  inasmuch  as  we  possess 
no  observations  which  would  substantiate  this  view.  Arnaud  37 
reports  that  seventy-three  cases  of  dementia  paralytica  who 
died  at  the  Maison  de  Sante  Vauves  did  not,  during  the  ter- 
minal period  of  the  malady,  show  any  evidence  of  motor  im- 
potence, and  in  sixteen  instances  an  intercurrent  disease  was 
the  immediate  cause  of  death.  The  same  observer  affirms  that 
severe  trophic  disturbances  are  much  less  common  than  is 
generally  supposed. 

Differential  Diagnosis.38 — The  early  diagnosis  in 
many  cases  of  dementia  paralytica  is  exceedingly  difficult  and 
yet  is  one  that  is  frequently  of  momentous  importance.  The 
symptoms  of  paresis  may  be  grafted  upon  those  of  neuras- 
thenia, and  if  such  a  condition  exists  it  is  almost  impossible  in 
the  prodromal  period  to  recognize  the  onset  of  the  graver  dis- 
order. A  diagnosis  based  solely  upon  the  analysis  of  the  mental 
symptoms  is  very  apt  to  be  erroneous,  although,  broadly  speak- 
ing, the  limitations  in  connected  thinking  in  the  neurasthenic 
are  less  progressive  as  contrasted  with  those  in  the  paretic,  and 
in  the  former  are  not  commonly  associated  with  flagrant  defects 
in  the  aesthetic  and  moral  sense. 

In  paresis  the  symptoms  of  which  the  patient  complains  are 
apt  to  be  less  evanescent,  but  more  incongruous,  or  even  bizarre, 
than  are  those  in  neurasthenia.  The  general  practitioner  is  often 
greatly  embarrassed  when  forced  to  decide  whether  or  not  a 
patient  who  during  the  prime  of  life  begins  to  suffer  from 
gastric  disturbances,  a  disinclination  to  work,  an  inability  to 
focus  the  attention,  slight  lapses  in  memory,  restlessness,  an 
abulia  of  which  there  may  be  subjective  appreciation  without 
accompanying  physical  signs,  is  entering  upon  the  first  stage  of 

37  Sur  la  periode  terminale  de  la  paralysie  generate  et  sur  la  mort  des 
paralytiques  generaux.     Rev.  Neurol.,  Aout  31,  1903. 

38  Hoche :     Die  Friihdiagnose  der  progressiven  Paralyse.     Halle  a/S., 
1896.     Klippel :    Les  Paralyses  Generates  progressives.     Paris,  1898. 


DEMENTIA    PARALYTICA 


455 


this  form  of  alienation.  In  the  functional  as  well  as  in  the 
organic  disorder  we  may  have  signs  of  mental  depression  of 
which  the  patient  is  at  first  fully  conscious,  and  in  both  cases 
obsessions  as  well  as  phobias  may  play  an  important  role.  The 
gravity  of  the  prognosis  assumes  a  more  serious  aspect  when 
in  the  face  of  a  definite  history  of  alcoholism  the  mental  symp- 
toms become  markedly  progressive.  In  such  instances  not  only 
one,  but  several  careful  physical  examinations  should  be  made 
at  short  intervals  in  order  that  the  first  positive  symptom  of 
paresis  may  be  recognized.  It  is  in  just  such  doubtful  condi- 
tions that  the  method  of  cytodiagnosis,  first  introduced  by 
Widal,39  offers  an  important  adjunct  in  the  differentiation, 
since  the  occurrence  of  lymphocytes  in  the  spinal  fluid  would 
indicate  the  existence  not  necessarily  of  paresis,  but,  at  any  rate, 
of  some  organic  lesion.  In  regard  to  the  mental  symptoms  the 
appearance  of  a  mild  degree  of  apathy  and  indifference,  or  even 
the  suggestion  of  a  general  impairment  of  all  the  psychic  func- 
tions, no  matter  how  slight  this  involvement  may  be,  is  a  danger 
signal  of  more  significance  than  even  great  and  rapid  varia- 
tions in  the  emotional  life,  as  these  latter  are  not  uncommon  in 
psychasthenia.  In  the  classical  type  of  the  disease  the  conduct 
of  the  paretic  contrasts  strongly  with  the  general  bearing  of  the 
psychasthenic.  The  latter  seldom  becomes  active,  strenuous, 
determined,  or  bumptious,  but  is  indolent,  resigned,  never  litig- 
ious, and  is  evidently  a  person  whose  volitional  movements 
are  more  or  less  inhibited  and  restrained  through  doubt  or  fear, 
a  description  which  certainly  does  not  apply  to  the  paretic, 
except,  perhaps,  in  the  early  stages  of  the  depressed  type  of  the 
disease.  On  the  contrary,  paretics  are  prone  to  translate  their 
ideas  into  action  and  to  go  ahead  without  waiting  to  count  the 
cost.  Again,  the  insight  of  the  psychasthenic  into  his  own 
condition  is  better  preserved. 

The  diminution  in  the  consensual  light  reflex  or  the  ten- 
dency to  slur  syllables  as  well  as  a  general  incoordination  of 
the  muscular  movements,  when  taken  in  connection  with  the 

39  Widal  et  Ravaut :     Soc.  de  Biologie,  Juin  30,  1900. 


456  PSYCHIATRY 

mental  symptoms,  the  slight  lapses  in  consciousness,  the  tem- 
porary epileptiform  or  apoplectiform  attacks,  disturbances  in 
articulation,  the  ophthalmic  migraine,  and  the  temporary 
aphasias  or  pareses  of  the  extrinsic  muscles  of  the  eye,  are 
signs  of  positive  value.  The  mental  activity  of  the  paretic 
is,  as  a  rule,  considerably  impaired,  while  the  neurasthenic 
may  retain  much  of  his  normal  mentality,  although  attempts 
to  exercise  it  are  accompanied  by  an  increased  sense  of  effort 
and  fatigue. 

The  differentiation  from  hysteria  which  sometimes  com- 
plicates and  at  other  times  simulates  dementia  paralytica  is 
frequently  beset  with  many  difficulties,  and  in  the  absence  of 
the  somatic  symptoms,  particularly  in  men,  a  positive  opinion 
should  not  be  advanced.40 

It  must  not  be  forgotten  that  even  in  hysterical  seizures 
there  may  be  a  temporary  inhibition  in  the  light  reflex,  and  in 
all  doubtful  cases  judgment  should  be  suspended  until  the 
patient  has  recovered  from  the  immediate  effects  of  the  seizure, 
so  that  a  careful  examination  is  possible.  The  persistence  of 
an  impaired  light  reflex,  the  occurrence  of  difficulties  in  the 
enunciation  of  words,  and,  above  all,  the  presence  of  lympho- 
cytes in  the  cerebrospinal  fluid,  are  factors  that  should  be  con- 
sidered of  great  weight  in  the  establishment  of  the  diagnosis 
of  paresis. 

At  times  epileptic  attacks  may  give  rise  to  difficulties  in 
diagnosis,  and  it  is  frequently  necessary  to  keep  the  patient 
under  observation  for  some  time  before  the  final  decision  can 
be  made.  The  sudden  appearance  of  mania  with  excessive 
apprehensiveness,  exaggerated  fears,  varied  and  constant  hallu- 
cinations which  dominate  the  whole  conduct  of  the  individual 
are,  as  a  rule,  much  more  apt  to  be  indicative  of  the  existence 
of  the  functional  neurosis.  Even  in  the  most  acute  cases  of 
paresis  there  is  apt  to  be  a  prodromal  period  of  one  or  two 
weeks  prior  to  the  outbreak  of  the  graver  symptoms. 

Multiple  sclerosis,  particularly  in  its  early  stages  and  when 

40  Babinski :   Verhandlungen  der  Societe  med.  Hopitaux  de  Paris.   1892. 


DEMENTIA    PARALYTICA  457 

occurring  at  the  prime  of  life,  may  be  mistaken  for  general 
paresis.  The  emotional  conditions  in  the  two  disorders,  how- 
ever, are  apt  to  be  somewhat  different.  In  the  sclerotic  pro- 
cesses the  patient  frequently  suffers  from  sudden  and  inex- 
plicable outbursts  of  temper  of  which  he  generally  retains  a 
fairly  accurate  knowledge,  while  at  the  same  time  he  is  con- 
scious of  the  fact  that  such  anomalous  emotional  states  are 
decidedly  abnormal.  Nor  is  there,  as  a  rule,  any  marked  evi- 
dence of  any  general  mental  impairment.  The  paretic,  on  the 
other  hand,  may  be  subject  to  such  outbreaks,  but  these  are 
more  or  less  constantly  followed  by  apathy  or  an  indifference  as 
to  their  consequences.  The  appearance  of  the  scanning  speech 
and  the  intention  tremor  are,  of  course,  of  diagnostic  impor- 
tance. 

But  the  greatest  difficulty  in  making  a  decision  arises  in 
those  rare  cases  of  paresis  that  begin  with  a  sudden  onset  and 
in  many  respects  resemble  instances  of  delirium  acutum.  The 
history  of  some  direct  exciting  cause,  such  as  a  protracted  ill- 
ness, trauma,  some  severe  mental  shock,  hemorrhage,  the  pres- 
ence of  a  normal  light  reflex,  the  absence  of  a  protracted  neur- 
asthenic stage,  disturbances  in  articulation,  and  paretic  seizures, 
taken  together,  are  factors  that  are  indicative  rather  of  the  acute 
delirious  states  than  of  a  galloping  paresis. 

Reference  has  already  been  made,  when  speaking  of  the 
atypical  forms,  to  the  fact  that  it  is  frequently  impossible  to 
differentiate  a  paresis  coming  on  late  in  life  from  a  senile  de- 
mentia. The  clinical  symptomatology  of  chronic  alcoholism  or 
Korsakow's  syndrome  may  bear  a  striking  resemblance  to  that 
of  dementia  paralytica,  and  frequent  references  to  these  so- 
called  pseudoparetics  are  found  in  the  literature.  As  a  rule, 
the  speech  disturbances  of  alcoholism  are  distinguishable  from 
those  of  the  paretic,  the  former  being  characterized  by  greater 
tremulousness  and  less  difficulty  in  articulation  than  the  latter.41 
An  important  point  in  establishing  the  diagnosis  in  doubtful 
cases  is  that  an  alcoholic  frequently  recovers  to  quite  a  remark- 

41  See  Alcoholism,  Korsakow's  Syndrome. 


458  PSYCHIATRY 

able   extent,    provided   that   the   toxic    agent   be   withdrawn, 
whereas  paresis  is  apt  to  be  markedly  progressive. 

The  differentiation  from  cerebral  syphilis  is  frequently  dif- 
ficult. Although  the  luetic  infection  may  give  rise  to  cerebral 
disturbances  characterized  by  more  or  less  localized  motor 
symptoms  combined  with  incoherence,  disorientation,  and  an 
hallucinatory  delirium  with  insane  ideas,  a  general  mental  im- 
pairment equal  to  that  wrhich  exists  in  the  cases  of  dementia 
paralytica  is  not  observed.  In  lues  the  speech  disturbance  is 
less  pronounced  and  far  less  characteristic  than  in  paresis.  The 
tendency  of  the  syphilitic  process  to  become  more  or  less  local- 
ized is  an  important  factor  that  should  always  be  kept  in  mind. 
We  not  infrequently  meet  with  disturbances  in  the  course  of 
syphilis  which  may  give  rise  to  suspicion  of  a  beginning  de- 
mentia paralytica,  particularly  when  the  Argyll-Robertson  pupil 
is  present,  together  with  a  marked  tendency  to  mental  and  phy- 
sical fatigue,  impairment  of  memory,  and  slight  disturbances  in 
speech. 

The  excited  or  depressed  states  occurring  during  the 
course  of  dementia  paralytica  may  be  mistaken  for  somewhat 
similar  periods  in  manic-depressive  insanity.  The  essential 
points  in  the  diagnosis  have  been  fully  discussed  in  considering 
the  latter  psychosis. 

Treatment. — Reference  has  already  been  made  to  the 
factors  that  must  be  regarded  as  of  etiologic  importance,  and  it 
is  unnecessary  to  repeat  here  what  has  already  been  said  in 
regard  to  prophylaxis.  As  soon  as  a  positive  diagnosis  of  gen- 
eral paresis  has  been  arrived  at  the  alienist  should  at  once  ex- 
plain the  gravity  of  the  prognosis  to  members  of  the  family  or 
friends  and  advise  the  immediate  removal  to  an  institution 
where  the  patient  can  be  under  constant  supervision.  Among 
the  wealthier  classes,  where  it  is  possible  to  secure  the  services 
of  trained  nurses,  so  that  constant  intelligent  supervision  can  be 
guaranteed,  and  if  the  family  is  willing  to  take  the  full  responsi- 
bility of  possible  accidents  in  the  earlier  stages,  the  patient  may 
be  treated  at  home.  But  the  fact  should  be  emphasized  by  the 
physician  that  such  a  course  is,  as  a  rule,  inadvisable,  as  such 


DEMENTIA    PARALYTICA 


459 


patients  can  receive  much  better  care  in  an  appropriate  institu- 
tion. Patients  suffering  from  the  classic  type  of  the  disease 
while  in  the  hospital,  except  during  the  excited  periods,  do  not 
need  to  be  as  closely  watched  as  those  afflicted  with  the  de- 
pressed form,  as  the  latter  are  much  more  prone  to  mutilate 
themselves  or  commit  suicide.  In  the  prodromal  period  or 
the  early  part  of  the  second  stage  nearly  all  patients  should 
receive  the  possible  advantages  of  anti-syphilitic  treatment. 
This  may  be  given  either  in  the  form  of  inunctions  or  by  the 
internal  administration  of  mercury  either  alone  or  combined 
with  the  iodides,  according  to  the  indications  in  each  case.  The 
results  obtained,  however,  are  seldom  gratifying.  In  the  later 
stages  of  the  disease  the  symptoms,  as  they  arise,  are  treated 
purely  symptomatically.  At  all  stages  hydrotherapeutic  meas- 
ures, either  in  the  form  of  packs  or  prolonged  baths,  as  the  indi- 
cations arise,  are  distinctly  beneficial.  As  a  rule,  such  patients 
are  much  better  off  without  alcohol  in  any  form,  although  in 
cases  of  collapse  or  in  the  terminal  stages  it  is  frequently  neces- 
sary to  resort  to  small  doses  of  the  drug.  In  cases  of  sexual 
excitability,  in  addition  to  the  baths,  small  doses  of  the  bromides 
are  frequently  of  great  value.  Insomnia  is  frequently  distress- 
ing, particularly  during  the  periods  of  greatest  excitement,  and 
may  be  combated  by  the  ordinary  hydrotherapeutic  measures 
or  by  the  administration  of  chloralamid.  hyoscin,  sulfonal,  mor- 
phin,  or  bromides,  as  well  as  by  the  application  of  cold  com- 
presses to  the  head,  while  the  patient  is  kept  in  a  continuous 
warm  bath  for  three  to  four  hours.  During  the  paralytic  attacks 
it  is  frequently  impossible  to  feed  the  patient  except  by  rectum. 
At  such  times  benefit  may  be  derived  from  salt  injections  either 
alone  or  combined  with  the  various  substances  mentioned  in  the 
first  section  of  the  book.  In  retention  of  urine  great  care  must 
be  taken  in  the  catheterization  that  no  infection  is  carried  to  the 
bladder,  since  in  the  weakened  condition  of  the  patient  a  cystitis 
will  surely  form  a  complication  and  may  result  fatally.  When 
the  mentality  is  greatly  impaired  care  should  be  taken  that  the 
patients  do  not  choke  themselves  to  death  by  swallowing  their 
food  without  mastication.    So  far  as  drugs  are  concerned,  ergot 


460  PSYCHIATRY 

injections  have  been  recommended,  and  the  withdrawal  of 
cerebrospinal  fluid  under  careful  aseptic  precautions  has  been 
said  to  be  followed  by  amelioration  or  cessation  of  the  para- 
lytic attacks. 

At  all  times  skilled  nursing  is  absolutely  essential,  adding 
greatly  to  the  comfort  of  the  patient,  preventing  complications, 
and  prolonging  life.  As  such  patients  are  at  times  very  dirty 
in  their  habits  great  care  must  be  taken  to  avoid  bed-sores,  as 
the  most  simple  localized  infection  may  prove  a  menace  to  life. 
All  points  of  pressure  should  be  relieved  as  far  as  possible  by 
bathing  with  soap  and  warm  water  or  a  mixture  of  water  and 
alcohol,  by  the  support  of  rubber  cushions,  and  by  hardening  the 
skin  with  zinc  ointment.  The  bowels  must  be  carefully  regu- 
lated, and  if  marked  constipation  is  present  small  doses  of 
calomel  frequently  repeated  at  intervals  are  of  great  value. 
During  the  remissions  the  patient  may  be  allowed  to  return  to 
his  home  provided  that  he  can  still  be  kept  under  constant 
medical  supervision. 

The  injections  of  salt  solution  have  been  tried  with  favor- 
able results  in  a  number  of  cases.  The  saline  infusions  were 
first  used  in  1890  by  Stahli  in  various  forms  of  intoxications. 
Recently  they  have  been  tried  in  cases  of  dementia  paralytica.42 
The  method  of  procedure  has  been  described  in  detail  in  the 
first  section  of  the  book,  in  which  the  formula  for  the  fluid  which 
seems  to  afford  the  best  results  has  also  been  given.  In  addition 
to  the  infusions  rectal  injections  of  salt  solution  are  frequently 
beneficial.  During  this  treatment  the  patient  should  be  kept 
quietly  in  bed  and  preferably  on  a  fluid  diet. 

Pathological  Anatomy. — In  general  paralysis  of  the 
insane  lesions  are  found  in  nearly  all  the  internal  organs,  and 
even  in  patients  who  die  early  in  the  disease  the  changes  are  not 
by  any  means  confined  to  the  central  nervous  system.  The 
visceral  lesions  have  been  extensively  studied  and  may  be  classi- 


42  Donath,  Julius :  Die  Behandlung  der  progressiven  Paralyse,  sowie 
toxischer  und  infectioser  Psychosen  mit  Salzinfusionen.  Allg.  Ztschr.  f. 
Psych,  u.  psych. -gericht.  Med.,  1903,  Bd.  lx,  H.  4. 


DEMENTIA    PARALYTICA  461 

fied  as  follows :  43  ( 1 )  those  preceding  the  development  of  the 
malady,  such  as  alcoholic  cirrhoses,  tuberculous  processes;  (2) 
lesions  that  are  more  directly  related  to  the  disease  process, — 
chronic  congestions,  visceral  hemorrhages;  (3)  passive  conges- 
tions; (4)  secondary  infections  (pneumococcus,  streptococcus, 
bacillus  coli).  Among  the  pulmonary  lesions  we  not  infre- 
quently meet  with  congestions,  catarrhal  or  lobar  pneumonias, 
emphysema,  gangrene,  and  tuberculous  infections.  The  heart  is 
nearly  always  affected,  myocarditis  or  endocarditis  being  often 
found.  The  liver,  stomach,  and  pancreas  are  the  seat  of  chronic 
as  well  as  acute  pathological  processes,  and  the  kidneys  are 
practically  never  normal.  Generally  vascular  lesions  are  almost 
always  present  in  varying  degrees  of  intensity.  The  widespread 
character  of  the  changes  gives  rise  to  a  marked  cachexia,  which 
is  at  once  apparent  in  nearly  every  case. 

The  bones  of  the  skull  are  frequently  altered.  Robertson  44 
affirms  that  there  is  a  condensation  of  the  bones,  sometimes 
but  not  always  accompanied  by  a  thickening,  while  the  diploe 
is  frequently  thinner  and  the  bony  substance  may  be  replaced 
by  cancellous  material.  In  other  instances  the  bones  may  be 
greatly  thickened  and  increased  in  weight,  and  along  the  inner 
surface  of  the  skull  bony  protrusions  of  considerable  size  are 
often  found.  Fraenkel's45  investigations  led  him  to  believe 
that  the  weight  of  the  skull  in  general  paresis  is  greater  than  in 
any  other  form  of  mental  disease,  but  this  observation  has  not 
been  generally  substantiated. 

Membranes. — The  dura  may  have  a  normal  appearance, 
but  frequently  is  thicker  than  in  other  psychoses  and  gives 
evidence  of  a  pachymeningitis  externa.  The  statement  that  a 
pachymeningitis  hsemorrhagica  interna  exists  in  fully  half  the 
cases,  however,  needs  confirmation,  although  it  cannot  be  denied 
that  such  a  condition  is  sometimes  present.  In  the  more  recent 
cases  one  is  apt  to  find  a  fibrinous  exudate  which  in  places  may 


*"  Klippel :    Arch,  de  med.  experiment.,  Tuillet,  1892. 

**  Pathology  of  Mental  Diseases.     Edinburgh,  1900,  p.  68. 

46  Riv.  sperimentale  di  Freniatria,  vol.  i. 


462  PSYCHIATRY 

show  signs  of  organization.  It  was  formerly  believed  that 
localized  hemorrhages  of  considerable  size  were  not  un- 
common, but  true  hasmatomata  are  rare,  and  Gross  in  124 
autopsies  on  patients  dead  of  paresis  found  them  in  only 
5  instances.  A  similar  conclusion  as  to  their  rarity  has 
more  recently  been  expressed  by  Fiirstner.46  When  haema- 
tomata  do  exist,  however,  they  are  found  either  over  one  or 
both  hemispheres  and  in  rare  instances  may  attain  quite  a  con- 
siderable size.  Extensive  adhesions  between  the  dura  and  pia 
are  common,  but  over  the  convexity  the  latter  is  usually  opaque 
and  thickened,  the  change  being  first  apparent  along- the  course 
of  the  vessels.  Over  the  basal  portion  of  the  pia  they  are  less 
marked.  Frequently  when  the  pia  is  stripped  off  from  the  brain 
a  marked  decortication  takes  place,  showing  the  existence  of  a 
leptomeningitis  chronica  profunda.  The  increase  in  the  con- 
nective tissue  of  the  pia  and  subarachnoid  tissue  is  frequently 
noticeable  even  in  the  early  stages  of  the  disease,  although  it  is 
not  uncommon  at  this  period  to  find  the  pia-arachnoid  tissue 
filled  with  leucocytes.  The  ependymal  lining  of  the  ventricles 
is  often  thickened,  presenting  a  granular  appearance,  and  its 
epithelial  layer  is  degenerated. 

The  changes  in  the  blood-vessels  of  the  membranes  fre- 
quently apparent  on  macroscopic  examination  are  not  specific 
of  the  disease,  inasmuch  as  similar  conditions  are  seen  in  alco- 
holics and  various  forms  of  chronic  dementia. 

The  weight  of  the  brain  is  generally  diminished  (Jen- 
sen).47 The  weight  of  the  brain  of  paretics  is  about  150 
grammes  below  the  average  of  those  individuals  who  have 
not  suffered  from  mental  disorders.  This  question,  however, 
is  one  that  can  not  be  settled  offhand,  as  the  discrepancies  in 
the  various  recorded  observations  are  too  great  to  be  easily 
explained.  Marchand  gives  the  average  weight  of  the  brain 
of  the  normal  man,  between  40  and  49,  as   1403  grammes, 

46  Fiirstner :    Monatsschr.  f.  Psych,  u.  Neurol.,  November,  1902. 

47  Arch.  f.  Psych.,  1888,  Bd.  xx.  Ilberg,  Georg :  Gewicht  d.  Gehirns  u. 
seines  Theiles,  v.  102  an  Dement.  Paralyt.  verstorb.  mannlichen  Sachsen. 
Allg.  Ztschr.  f.  Psych,  u.  psych.-gericht.  Medizin,  Bd.  xl,  H.  3. 


PLATE   XI 


&m 


Section  of  cortex  from  a  case  of  paresis,  showing  thickening  of  pia  arachnoid  and  adhesions 
between  pia  arachnoid  and  cortex.    X  50.    Zeiss  planar,  20  mm.    (Cramer  isochr.  plate.) 


PLATE   XII  (? 


X.K.W_ 


x.xim 


Gyrus  occipitalis. 


Gyrus  praecentralis. 


The  four  drawings  (Plates  XII  a  and  XII*)  were  made  from  sections  of  the  cerebral 
cortex  of  a  man  aged  30.  Thickness  of  section,  40^.  Stained  by  original  Weigert  method. 
(No  recorded  history  of  mental  disease.) 


PLATE,  XII  b 

VIZ 


-?-- 


TOOK- 


I1A. 


Gyrus  postcentralis. 


Gyrus  frontalis  ( superior). 


DEMENTIA    PARALYTICA  463 

but  the  extreme  limits  of  this  so-called  normal  weight  may 
vary  between  1250  and  1550  grammes.  The  specific  gravity 
of  the  cerebral  cortex  is  said  to  be  diminished  in  the  more 
chronic  cases.  The  ventricles  are  often  dilated  and  there  is 
a  marked  atrophy  of  the  cortex  most  noticeable,  as  a  rule,  in 
the  frontal  and  parietal  areas.  This  can  be  seen  in  freshly 
cut  sections,  the  atrophy  being  usually  more  marked  at  the 
base  than  at  the  summit  of  the  convolution. 

Two  main  views  are  held  in  regard  to  the  disappearance  of 
the  fibres  from  the  cerebral  cortex  in  cases  of  paresis.  The 
earlier  investigations,  particularly  those  of  Tuczek,  render  it 
probable  that  in  certain  cortical  areas,  particularly  in  the  cen- 
tral and  occipital  convolutions,  the  fibres  are  not  severely 
affected.  This  same  view  has  been  more  recently  advocated  by 
Schaeffer.48  Lawrence,49  after  a  series  of  very  careful  and  de- 
tailed studies,  concludes  that  in  the  brains  which  he  has  studied 
the  pathological  process  was  more  severe  in  the  central  and 
frontal  regions.  Nevertheless,  Kaes,50  after  very  extended  ob- 
servations, arrives  at  a  different  conclusion.  Instead  of  the 
localized  disappearance  of  fibres  the  latter  finds  that  the  paretic 
process  is  a  general  atrophy,  not  only  of  the  zonal  fibres,  but 
of  those  in  the  second  and  third  Meynert  layers,  as  well  as  in 
the  Baillarger-Gennari  stripes.  The  disappearance  of  the  fibres 
is  essentially  diffuse.  In  the  areas  where  the  fibres  are  not  so 
densely  packed  a  complete  absorption  may  occur,  but  in  the 
deeper  areas  of  the  cortex,  where  the  fibres  are  thicker,  this 
rarely  takes  place.  The  necessity  of  further  careful  compara- 
tive studies  of  all  the  different  cortical  areas  is  essential.  The 
relationship  between  the  extent  of  the  disappearance  of  the 
fibres  and  the  duration  of  the  disease  seems  to  be  more  or  less 


48  Schaeffer,  Karl :  Ueber  Markfasergehalt  eines  normalen  und  eines 
paralytischen  Gehirns.  Neurolog.  Centralbl.,  1903,  September  1,  Nr.  17, 
S.  802. 

43  Studies  upon  the  Cerebral  Cortex  in  the  Normal  Human  Brain 
and  in  Dementia  Paralytica.  Journ.  of  Nerv.  and  Ment.  Disease,  Nos.  10, 
11,  12,  1903. 

E0  Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  xii,  H.  5. 


464  PSYCHIATRY 

definite.  The  general  consensus  of  opinion  is  against  the  view 
that  any  direct  relationship  exists  between  the  meningeal 
changes  and  the  atrophy  of  the  fibres.  Frequently  the  nerve- 
fibres  in  the  cortex  appear  to  be  swollen  and  not  infrequently 
show  marked  varicosities,  being  at  times  broken  up  into  little 
balls.  Some  observers  have  reported  the  occurrence  of  hyper- 
trophied  axis-cylinders  in  nearly  all  cases  of  paresis.  Not  only 
are  the  fibres  in  the  various  cortical  areas  affected,  but  marked 
changes  have  been  observed  in  the  basal  ganglia  as  well  as  in 
the  medulla  and  spinal  cord.  Not  infrequently  areas  of  de- 
generation may  be  found  in  the  optic  thalamus  and  in  some 
cases  in  the  gray  matter  surrounding  the  third  ventricle.  Lis- 
sauer  states  that  in  a  few  of  the  atypical  cases  the  pathological 
changes  are  most  marked  in  this  subcortical  centre. 

Nerve-Cell  Changes}1 — Inspection  of  the  cortex  with  a 
low-power  lens  in  stained  specimens  often  shows  a  notable  dis- 
appearance of  cells.  Where  the  atrophy  is  marked,  if  the  sec- 
tion is  studied  under  the  low  power  of  the  microscope  the  nor- 
mal columnar  arrangement  of  the  cells  in  rows  is  seen  to  be 
broken  up,  while  practically  all  conceivable  changes  are  observed 
in  the  cells.     These  have  been  described  in  detail  by  Hoch.52 

The  nerve-cell  changes  may  be  described  as  (1)  acute, 
characterized  by  swelling  of  the  cell-body,  which  tends  to  stain 
diffusely,  and  an  increase  in  the  size  of  the  nucleus,  and  finally 
a  more  or  less  disintegration  of  the  whole;  (2)  a  chronic  form, 
in  which  the  axis-cylinders  show  a  marked  tendency  to  stain 
more  or  less  deeply,  and  a  granular  appearance  of  the  body, 
with  a  tendency  to  stain  faintly;  (3)  a  cell  sclerosis,  another 
chronic  change  frequently  met  with,  in  which  the  processes  be- 
come tortuous,  stain  deeply;   the  cell-bodies  have  a  shrunken 


51  Binswanger :  Die  pathologische  Histologic  der  Grosshirnrinden- 
Erkrankungen  bei  der  allgemeinen  progressiven  Paralyse,  1893.  Nissl : 
Archiv  f.  Psych.,  Bd.  xxviii,  S.  989.  Heilbronner:  Allgem.  Ztschr.  f. 
Psych.,  Bd.  liii,  S.  172. 

M  Hoch,  A. :  On  Changes  in  the  Nerve-Cells  of  the  Cortex  in  a  Case 
of  Acute  Delirium  and  a  Case  of  Delirium  Tremens.  Am.  Journ.  Insan., 
vol.  liv,  1898. 


DESCRIPTION   OF   PLATE   XIII. 

Fig.  i. — Cross-section  cerebral  cortex  (gyrus  centralis  posterior,  culmen). 
Normal  adult  male. 

Fig.  2. — Same  area  from  a  case  of  dementia  paralytica.  The  drawings 
include  four  external  layers  of  cortex  :  I,  Lamina  zonalis.  II,  Lamina 
granulans  externa.  Ill,  Lamina  pyramidalis.  IV,  Lamina  granulans  in- 
terna. 

The  nerve-cells  in  Fig.  i  show  plainly  the  fibrillary  structure  and  great 
numbers  of  finely  branching  dendrites.  The  very  long  pointed  processes 
are  particularly  prominent  in  the  large  pyramidal  cell  layer.  The  nucleus  is 
not  stained.  The  portion  of  field  not  occupied  by  cells  is  filled  in  by  a  felt- 
ing (Filz)  of  very  fine  medullated  and  non-medullated  nerve-fibres  and 
branching  dendrites. 

In  Fig.  2  it  will  be  noticed  that  the  nerve-cells  are  much  closer  together, 
while  the  cell  bodies  have  an  homogeneous  dark  appearance  with  only  an 
occasional  suggestion  of  the  normal  fibrillary  structure.  The  dendrites  are 
either  absent  or  are  shortened,  tortuous,  and  swollen.  The  extracellular 
felting,  particularly  in  layer  I,  is  markedly  thinner.  The  disappearance  of 
elements  from  the  field  includes  the  finest  structures.  If  this  section  is  com- 
pared with  one  stained  by  the  Weigert  method,  the  appearance  in  the  field 
of  the  large  number  of  fibres  in  spite  of  the  severe  affection  of  the  cellular 
elements  is  very  striking. 


PLATE  Xni 


Fig.  i. 


Fig.  2. 


PLATE   XIV 


p1G-  3 —Normal  giant  or  Betz  cell  in  the  gyrus  centralis  anterior. 
Fig.  4.— Giant  cell  from  same  area.     Case  of  dementia  paralytica. 

The  above  drawings  were  made  from  original  preparations  kindly  loaned  by-  Drs.  Biel- 
schowsky  and  Brodmann  of  the  Neurobiological  Institute,  Berlin.  The  sections  were  stained 
by  the  Bielschowsky  fibril  stain.  Figs.  1  and  2,  Zeiss,  oc.  4.  Pigs.  3  and  4,  homogen. 
immers.  t'ts,  oc.  2. 


DEMENTIA    PARALYTICA  465 

appearance,  and  many  of  them  seem  to  be  partially  filled  with 
a  bright  yellow  pigment. 

Whether  the  acute  changes  stand  in  direct  relationship  to 
the  paretic  process,  or  whether  they  develop  in  the  terminal 
stage,  as  the  result  of  infections  or  of  the  acute  symptoms  aris- 
ing from  complications  developing  in  connection  with  the  kid- 
neys, heart,  lungs,  or  other  internal  viscera,  it  is  difficult  to  say. 
It  may  be  laid  down  as  a  general  rule  that  in  other  diseases 
where  similar  cell  changes  are  observed — in  senile  dementia 
and  epilepsy — they  are  frequently  so  widespread  as  to  render 
it  improbable  that  the  disease  process  is  cortical  in  origin.  In 
addition  to  these  changes,  it  is  not  uncommon  to  find  small  or, 
more  rarely,  large  areas  of  sclerosis  scattered  through  the  cen- 
tral nervous  system. 

The  Neuroglia  Changes. — Anomalies  in  the  structure  of 
the  neuroglia  are  met  with  in  every  case  of  dementia  paralytica. 
The  findings  in  the  acute  and  chronic  cases  differ  essentially. 
Generally  there  is  a  proliferation  of  the  fibres,  which  is  much 
more  marked  in  the  latter  than  in  the  former.  As  a  rule,  there 
is  an  increase  in  the  subpial  felting,  not  uniform,  but  more 
marked  in  some  places  than  in  others.  Bands  of  fibres  may 
be  noticed  along  the  blood-vessels.  The  abnormal  growth  of 
fibres  is  frequently  excessive  along  the  ependymal  lining  of 
the  central  gray  masses.  In  the  acute  cases  the  cells  appear 
as  if  they  were  reacting  to  some  stimulus;  there  is  a  marked 
increase  of  the  protoplasm  surrounding  the  nucleus,  so  that 
not  infrequently  the  cell-body  reaches  large  dimensions.  In 
the  case  from  which  the  illustration  was  taken  quantities 
of  large  spider-cells  were  found  in  the  molecular  layer,  being 
most  numerous  in  the  outer  half.  A  few  were  found  along  the 
inner  portions  of  the  layer,  where  it  comes  into  contact  with  the 
small  pyramidal  cells.  These  monster  cells  vary  in  size.  Not 
only  is  the  protoplasm  surrounding  the  nucleus  hypertrophic, 
but  in  many  instances  the  nuclei  themselves  are  larger  and  paler 
in  color  than  normal.  The  nuclei  are  altered  in  shape,  some  are 
oval,  others  present  a  notched  appearance,  while  still  others 
are  sausage-shaped  or  have  a  dumb-bell  form.    Great  numbers 

30 


466  PSYCHIATRY 

of  these  large  cells  may  be  present,  and  under  this  condition  the 
increase  of  the  neuroglia  fibres  is  not  well  marked.  The  forma- 
tion of  fibres  belongs  to  a  later  stage.  Many  authorities  hold 
that  the  hypertrophic  glia-cells  separate  themselves  from  the 
fibres,  and  that  the  former,  under  the  influence  of  a  chemotactic 
stimulus,  wander  towards  the  source  of  greatest  irritation.  In 
the  acute  stages  evidences  of  cell  mitosis  are  frequently  ob- 
served. The  neuroglia  cells  not  infrequently  surround  the 
nerve-elements  (the  so-called  accompanying  or  "  Trabant" 
cells).  In  some  sections  the  appearance  of  an  actual  encroach- 
ment of  the  glia  upon  the  nerve-cells  is  met  with.  These  are 
the  factors  which  suggested  to  Marinesco  the  term  neurono- 
phagia.  Occasionally  a  monster  cell  shows  a  double  nucleus. 
The  terminal  stage  in  the  transformation  of  the  cell  is  appar- 
ently the  production  of  fibres.  In  the  more  chronic  cases,  as  has 
already  been  said,  the  increase  of  fibres  is  the  most  noticeable 
finding  in  connection  with  the  neuroglia  changes.  Here  we  find 
few,  if  any,  of  the  large  cells.  The  subpial  felting  is,  as  a  rule, 
greatly  increased.  The  fibres  in  the  earlier  stages  are  some- 
times thick  and  have  a  swollen  appearance.  In  some  instances 
we  meet  with  amyloid  bodies.  Redlich  believes  that  these  are 
formed  in  the  glia-cells.  In  the  case  described  53  by  Rusk  and 
the  author,  the  former  referred  to  the  presence  of  certain  spher- 
ical bodies  with  regular  outlines  and  of  a  homogeneous  nature, 
which  stained  indifferently  with  any  acid  or  basic  stain  and 
readily  decolorized,  but  did  not  give  the  reaction  for  amyloid  or 
fat.  The  unusually  important  role  played  by  the  neuroglia 
nuclei  has  been  pointed  out  by  Nissl.54 

Lesions  in  the  sympathetic  probably  occur  in  all  the  cases, 
and  unquestionably  give  rise  to  many  of  the  symptoms  that 
occur.  Recently  the  solar  plexus  has  been  carefully  studied  in 
a  number  of  cases  by  Laignel  and  Lavastine,55  who  have  de- 
scribed a  variety  of  lesions  which  were  more  or  less  constant. 

M  Op.  cit. 

"Arch  f.  Psych.,  Bd.  xxxii,  H.  2. 

50  Histol.  Pathologie  du  Plexus  Solaire  chez  les  paralytiques  generaux. 
Revue  Neurologique,  1903,  Aout,  p.  827. 


PLATE  XV 


Giant  spider-cells,  cerebral  cortex  (Benda  stain).    X  1000.    (From  a  case  of  galloping  paresis.) 


PLATE    XVI 


Outer  layer  of  cerebral  cortex.    Case  of  acute  paresis.    Great  increase  in  number  of  giant 
spider-cells.     Benda's  neuroglia  stain  (Zeiss  comp.  oc.  No.  6,  obj.  2  mm.) 


DEMENTIA    PARALYTICA  467 

Among  the  more  noticeable  were  a  pigmented  atrophy  and  an 
interstitial  sclerosis.  The  cellular  changes  seemed  to  be  sec- 
ondary to  the  sclerotic  processes. 

The  Vascular  Changes. — The  vascular  changes  are,  as  a 
rule,  pronounced,  particularly  in  the  smaller  blood-vessels.  Ac- 
cording to  certain  observers  changes  occur  in  the  arteries  and 
veins  preceding  the  lesions  in  the  lymph-channels.  The  thick- 
ening of  the  membranes,  due  to  chronic  inflammatory  processes, 
causes  a  dilatation  of  the  subarachnoidal  lymph-spaces  and  a 
damming  up  of  the  venous  blood  supply,  so  that  His's  epicerebral 
space  is  obliterated  and  marked  changes  in  the  pial  vessels,  as 
well  as  in  the  small  arterioles  entering  the  superficial  layer  of 
the  cortex,  follow.  There  may  be  a  marked  increase  in  the 
nuclei  of  the  adventitia.  The  changes  are  not  confined  to  the 
arteries,  but  are  also  noticeable  in  the  veins.  There  is  a  dilata- 
tion of  the  intra-  and  extra-vascular  lymph-spaces.  Warda56 
has  found  that  the  hyaline  degeneration  extends  even  to  the 
capillaries  of  the  cortex,  and  associated  with  this  change  there 
is  a  marked  increase  of  the  adventitial  nuclei  as  well  as  of  the 
cells  forming  the  endothelial  lining.  In  many  instances  there  is 
a  marked  perivascular  infiltration  of  the  tissues.  The  adventi- 
tial spaces  are  dilated,  red  and  white  blood-cells  being  found  in 
the  perivascular  spaces.  Nonne  holds  that  the  vascular  changes 
of  paresis  do  not  correspond  with  the  picture  of  Heubner's 
endarteritis,  which  is  considered  by  many  the  crucial  pathologi- 
cal test  of  the  existence  of  syphilis.  In  the  acute  cases  it  is  ex- 
tremely difficult  to  say  whether  the  vascular  changes  precede  or 
are  secondary  to  the  alterations  in  the  neural  elements.  In  a 
few  cases  there  is  an  increase  in  the  intimal  constituents  that 
may  go  on  to  a  complete  occlusion  of  the  vessel.  Not  infre- 
quently the  vessels  show  small  aneurysmal  dilatations,  while  the 
evidences  of  the  formation  of  new  vessels  is,  as  a  rule,  fairly 
well  marked  and  more  striking  in  the  outer  layer  of  the  cortex. 
Vogt  and  Nissl  have  called  attention  to  the  occurrence  of 
epithelioid  Marschalko  plasma-cells  in  the  vessels.    This  finding 

56  Ztschr.  f.  Nervenheilk.,  Bd.  vii. 


468  PSYCHIATRY 

is  represented  in  the  accompanying  illustration.  The  appear- 
ance of  these  cells  indicates  the  existence  of  chronic  inflamma- 
tory changes,  so  that  to  a  limited  extent  they  afford  us  im- 
portant aid  in  distinguishing  the  paretic  processes  from  the 
cortical  changes  observed  in  certain  psychoses.  Of  course,  this 
does  not  apply  to  the  brain  diseases  which  are  commonly  re- 
ferred to  as  organic.  Havet 57  does  not  believe  that  the  plasma- 
cells  are  in  any  sense  pathognomonic  of  the  paretic  process. 
Sections  obtained  from  the  cerebral  cortex  in  the  various 
autopsies  performed  at  the  Sheppard  and  Enoch  Pratt  Hos- 
pital were  examined  by  Rusk  and  Dunton  with  a  view  to 
this  point,  and  their  results  tend  to  confirm  the  observations 
of  Vogt.  Plasma-cells  were  found  in  the  cortical  vessels  in 
cases  which  ran  an  acute  or  subacute  course,  but  in  material 
from  protracted  cases  they  were  not  demonstrable.  They 
have  not  been  observed  in  cases  of  dementia  prsecox  or  manic- 
depressive  insanity,  but  were  seen  in  one  case  of  a  young  boy 
who  had  been  subject  to  epileptiform  attacks  for  a  number 
of  years,  although  the  history  did  not  permit  a  positive  clinical 
diagnosis.  Weber  believes  that  the  plasma-cells  spring  from 
the  connective  tissue,  and  that  their  presence  indicates  a  more 
extensive  inflammatory  process  than  when  they  are  absent. 
Mahaim  found  in  certain  cases  numerous  cells  having  a  round 
nucleus  and  irregular  structure,  the  protoplasm  containing  vac- 
uoles, the  body  being  sometimes  large,  in  other  instances  small, 
and  containing  granulations  of  different  sizes  which  stained 
deeply. 

As  was  mentioned  when  discussing  the  clinical  symptoms, 
cases  of  paresis  are  not  rare  in  which  the  paretic  process  is  much 
more  pronounced  in  certain  areas  of  the  cortical  surface,  and 
this  localization  may  give  rise  to  focal  symptoms.  Adolf  Meyer 
has  reported  the  case  of  a  man  forty-two  years  of  age,  who  had 
difficulty  in  the  use  of  the  left  arm,  and  at  the  same  time  men- 
tally showed  slight  expansiveness.     As  the  case  progressed  an 

07  Bulletin  de  l'Acad.  de  Medecine  de  Belgique,  IV.  serie,  tome  xvi, 
No.  7,  Seance  du  26  Juillet,  1902. 


PLATE  XYII 


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Blood-vessel  from  cerebral  cortex  of  a  case  of  galloping  paresis,    a,  plasma  cells. 


DEMENTIA    PARALYTICA  469 

anaesthesia  of  central  origin  of  the  left  arm  was  found  to  be 
present.  Associated  with  these  symptoms  there  were  slow,  in- 
coordinated,  and  involuntary  movements  in  this  arm,  a  gradual 
development  of  rigidity  of  the  musculature  on  the  whole  left 
side,  and  a  left  hemiplegia.  At  autopsy  the  posterior  part  of 
the  right  hemisphere  was  found  to  be  the  seat  of  the  paretic 
process.  No  focal  lesions  were  present.  There  was  marked 
atrophy  of  the  cortex  and  a  distention  of  the  ventricles  with 
gliosis  of  the  left  portion  of  the  cerebellum.  Similar  cases  have 
been  described  by  Hoch.  In  this  connection  Bleuler  58  has  re- 
ported an  instance  of  unilateral  delirium  occurring  during  the 
course  of  general  paresis. 

These  cases  are  thought  by  some  observers  to  be  essentially 
different  from  those  in  which  the  paralytic  process  is  compli- 
cated by  a  focal  lesion.  In  view  of  the  more  recent  investiga- 
tions of  Kaes  59  and  others,  which  indicate  that  in  at  least  a 
majority  of  the  cases  the  pathological  process  is  generalized 
and  not  local,  we  are  unable  to  explain  the  occurrence  and  sig- 
nificance of  these  atypical  forms.  Probably,  however,  certain 
of  the  supposed  atypical  unilateral  cases  of  general  paresis  are 
complicated  by  arterio-sclerosis.  The  apparent  localization  of 
the  paretic  process  to  one  cortical  area  is  explicable  on  the 
ground  that  there  is  a  vascular  lesion  similar  to  that  described 
by  Alzheimer,  giving  rise  to  an  atrophy  and  reaction  in  the 
nerve  and  neuroglia  tissue  difficult  to  differentiate  from  the 
changes  occurring  during  paresis.  These  arterio-sclerotic  le- 
sions may  precede  the  development  of  the  paretic  process.  Fur- 
ther investigation  is  needed  in  relation  to  these  points. 

For  the  exact  nature  of  the  pathological  process  different 
explanations  have  been  offered.  Nissl 60  affirms  that  paresis  is 
a  chronic  inflammation  of  the  central  nervous  system,  and  that 
the  facts  justify  the  attempted  differentiation  between  this  dis- 
order and  other  psychoses  on  a  histo-pathological  basis.     The 


Halbseitiges  Delirium.     Psych,  neurol.  Wchnschr.,  1902,  34. 
Op.  cit. 
1  Neurolog.  Centralbl.,  1902,  December  16,  Nr.  24. 


47o 


PSYCHIATRY 


lesions  present  indicate  an  inflammation,  which  is  character- 
ized by  a  marked  infiltration  of  the  adventitial  sheaths,  with 
the  occurrence  of  the  plasma-cells.  From  these  findings  the 
deduction  is  made  that  an  inflammatory  process  is  the  basis 
of  the  changes,  and  that  the  latter  can  not  be  the  result  of  a 
simple  degeneration. 

As  the  result  of  two  hundred  autopsies  performed  by  Vig- 
ouroux  and  Laignel-Lavastine 61  on  patients  who  had  died 
from  dementia  paralytica,  these  observers  concluded  that  the 
pathological  processes  could  be  divided  into  three  categories : 
( i )  cases  in  which  there  was  a  general  cellular  infiltration  of 
the  meninges  and  cortex  not  accompanied  with  marked  degen- 
erative lesions  of  the  arteries;  (2)  instances  of  marked  hyaline 
degeneration  and  pigmentation  in  addition  to  the  infiltration, 
and  (3)  cases  characterized  by  marked  degeneration  of  the 
arteries  with  or  without  a  discrete  infiltration. 

More  recently  Nissl  62  has  attempted  to  draw  even  sharper 
lines  between  the  histo-pathological  changes  of  cerebral  lues 
and  those  that  occur  in  paresis.  As  has  already  been  mentioned, 
the  important  point  in  the  differentiation  is  to  be  sought  not  in 
single  lesions,  but  in  the  totality  of  the  findings.  The  paretic 
process  may  be  regarded  as  diffuse  in  the  sense  that  changes  are 
present  throughout  the  whole  cortical  region,  but  those  which 
are  specific  of  paresis  need  not  show  an  equal  intensity  in  all 
the  different  areas,  but  are  in  a  sense  localized.  This  idea  ren- 
ders it  possible  to  draw  a  distinction  between  the  typical  and 
atypical  cases.  A  resume  of  the  changes  which  may  be  regarded 
as  specific  of  general  paresis  is  as  follows : 

( 1 )  A  marked  disappearance  of  the  tangential  and  supra- 
radiary  fibres. 

(2)  An  increase  and  thickening  of  the  glia  fibres,  particu- 
larly the  subpial  felting,  as  well  as  of  the  bands  of  fibres  around 
the  blood-vessels ;  a  considerable  increase  in  the  number  of  cells 


61  Revue  Neurol.,  Aout  31,  1903. 

62  Nissl :    Zur  Lehre  von  der  Hirnlues.     Centralbl.  f.  Nervenheilk.  u. 
Psych.,  1903,  December  15,  Nr.  167,  S.  788. 


PLATE  XVIII 


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PLATE  XIX 


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a 

Rod  cells  from  the  cortex  in  paresis. 

Fig.  i. — Isolated  forms.  In  the  one  to  the  right  is  shown  a  pigmentary  deposit  in  the  protoplasm 
of  the  longer  polar  process. 

Fig.  2. — Capillary  containing  plasma  cells.  A  mural  element  (adventitial)  lies  alongside  of,  but 
entirely  separated  from,  the  vessel  wall.  This  element  has  the  morphological  characteristics  of  the 
rod  cells  which  are  scattered  through  the  grey  matter. 

Fig.  3. — Mural  element  separating  itself  from  the  vessel  wall,  but  not  yet  entirely  free. 

Drawings  from  sections  stained  with  polychrome  methylene-blue.  Zeiss,  homog.  immers.  1-30. 
Ocular  iv. 


DEMENTIA    PARALYTICA  471 

with  progressive  changes  in  the  nuclei  and  a  synchronous  thick- 
ening and  increase  in  the  size  of  the  cell-body,  and  a  differentia- 
tion particularly  of  thick  glia  fibres  out  of  the  protoplasm. 

(3)  The  appearance  of  various  lesions  in  the  nerve-cell. 

(4)  The  adventitial  spaces,  particularly  of  the  middle- 
sized  vessels,  contain  plasma-cells,  lymphocytes,  and  occasion- 
ally mast-cells.  In  the  adventitial  sheath  there  is  nearly  always 
pigmentation. 

(5)  A  formation  of  new  vessels  with  numerous  connec- 
tions between  the  glia  protoplasm  and  the  vessel  walls. 

(6)  The  so-called  Rods  (Stabchenzellen)  are  not  so  nu- 
merous in  any  other  process. 

(7)  The  characteristic  changes  in  the  spinal  cord. 
The  syphilitic  process  may  be  differentiated  as  follows  : 

( 1 )  A  relatively  slight  disappearance  of  the  tangential  and 
supra-radiary  fibres. 

(2)  A  different  character  in  the  glia  changes  from  that 
noticed  in  general  paresis.  The  throwing-off  of  the  glia  fibres 
is  less  marked,  and  the  large,  thick  fibres  are  not  common.  The 
bands  of  fibres  about  the  vessel  walls  are  less  prominent,  but 
the  thick  processes  connecting  the  cells  with  the  vessel  walls  are 
more  numerous.  The  nuclei  are  enormously  increased  and 
reach  a  colossal  size.  The  so-called  typical  glia  (gemastete) 
cells  are  absent,  and  the  cells  themselves  show  more  frequent 
regressive  changes. 

(3)  The  nerve-cells,  as  a  rule,  show  a  greater  tendency 
towards  swelling  and  disintegration  of  the  cell-body. 

(4)  There  is  at  the  most  only  a  very  slight  suggestion  of 
the  adventitial  infiltration,  with  only  an  occasional  mast-cell. 

(5)  A  marked  proliferation  of  the  cells  of  the  intima, 
which  show  an  inclination  to  form  small  vascular  lumina  inside 
of  the  original  vessel.  The  elastic  fibres  split  into  two  or  even 
four  or  five  layers.  The  formation  of  new  vessels  is  the  most 
characteristic  feature  in  the  picture.  The  cells  in  the  vessel 
walls  do  not  show  any  fat  pigment.  The  capillaries  frequently 
bore  through  the  glia  protoplasm. 

(6)  Rods  (Stabchenzellen)  are  rare. 


472 


PSYCHIATRY 


(7)  The  spinal  cord  shows  no  typical  degeneration. 

A  careful  analysis  and  comparison  of  all  the  facts  seems 
to  justify  the  view  that  dementia  paralytica  is  a  diffuse  toxic 
process  affecting  nearly  all  the  organs  in  the  body,  but  showing 
a  marked  predilection  for  the  central  nervous  system.  In  fact, 
we  have  a  series  of  phenomena  somewhat  analogous,  as  some 
observers  have  suggested,  to  the  cachexias  following  the  de- 
struction of  the  thyroid  or  suprarenal  bodies. 

It  is  interesting  to  note  that  Watson,63  in  studying  the 
central  nervous  system  of  cases  of  juvenile  general  paralysis, 
comes  to  the  conclusion  that  the  lesions  are  not  merely  the 
result  of  impaired  development,  but  of  some  active  process. 

63  The  Pathology  and  Morbid  Histology  of  Juvenile  General  Paralysis. 
Arch,  of  Neurol.,  ii,  1903. 


CHAPTER   XVI 

THE   EPILEPSY    GROUP1 

Epilepsy  is  a  disease  characterized  by  disturbances  in 
consciousness  of  varying  degrees  of  intensity,  with  or  without 
convulsive  seizures.  In  the  majority  of  cases  the  changes  in 
the  character  of  the  individual  noticeable  between  the  attacks 
are  almost  specific  and  may  manifest  themselves  in  either  a 
temporary  or  a  permanent  mental  aberration.  As  Binswanger 
has  shown,2  in  the  narrower  sense  only  those  cases  may  with 
certainty  be  called  epilepsy  in  which  the  symptoms  are  charac- 
terized by  chronicity  and  are  indicative  of  an  interference  with 
the  general  functions  of  the  central  nervous  system.  At  the 
outset  a  difficulty  in  regard  to  the  use  of  the  word  epilepsy  is 
experienced,  as  the  study  of  the  condition  to  which  the  term 
"  psychic  epilepsy"  has  been  applied  includes  a  variety  of  symp- 
toms. The  stable  epileptic  manifestations  are  referred  to  as 
changes  in  character  or  disposition,  while  the  episodic  forms  are 
associated  with  the  attacks  or  their  equivalents.  Hoffmann,  who, 
in  1862,  was  the  first  to  use  this  expression,  affirmed  that  it  was 
possible  to  recognize  the  disorder  in  cases  in  which  the  charac- 
teristic motor  anomalies  were  altogether  absent.  On  the  other 
hand,  a  reaction  has  taken  place,  and  the  general  consensus  of 
opinion  now  favors  the  view  that  in  the  absence  of  the  specific 
motor  symptoms  the  diagnosis  of  epilepsy  shall  be  made  with  a 
considerable  degree  of  mental  reservation.  The  observations 
of  Hoche  3  and  others  have  served  to  emphasize  the  extreme 

1  Gowers  :  Epilepsy  and  Other  Chronic  Convulsive  Diseases.  London, 
1901.  Dutil,  A. :  Troubles  mentaux  dans  l'epilepsie.  Ballet,  Traite  de 
pathol.  mentale.  Paris,  1903.  Starr,  M.  Allen :  Is  Epilepsy  a  Functional 
Disease?     Journ.  Nerv.  and  Ment.  Dis.,  March,  1904. 

2  Die  Epilepsie.  Specielle  Pathologie  und  Therapie.  Nothnagel, 
Wien,  1899. 

8  Hoche,  A. :  Die  Differentialdiagnose  zwischen  Epilepsie  und  Hys- 
teric    Berlin,  1902,  A.  Hirschwald. 

473 


474  PSYCHIATRY 

difficulty  that  frequently  exists  in  differentiating  cases  of  severe 
hysteria  from  epilepsy,  and  Aschaffenburg  has  recently  care- 
fully examined  a  number  of  cases  with  the  view  of  determining 
whether  in  many  of  the  presumed  instances  of  psychic  epilepsy 
a  positive  diagnosis  is  justifiable.  The  latter,  although  admit- 
ting the  relative  diagnostic  importance  of  such  symptoms  as 
headache,  profuse  sweating,  dilatation  of  the  pupils,  impaired 
reactions,  the  increase  in  the  rapidity  of  the  pulse,  the  marked 
tremor,  blanching  or  reddening  of  the  face,  the  severe  attacks 
of  diarrhoea,  etc.,  maintains  that  on  account  of  the  present  lim- 
itations of  our  knowledge  the  question  cannot  by  any  means 
always  be  answered  positively  in  the  affirmative.  After  these 
qualifying  statements  we  may  proceed  to  the  consideration  of 
the  clinical  forms  of  alienation  associated  with  this  neurosis. 

The  mental  disturbances  may  be  conveniently  arranged  in 
four  main  groups :  ( I )  those  that  precede  the  attacks, — the 
aurse;  (2)  those  that  develop  during  the  height  of  the  seiz- 
ure,— the  psychic  equivalents  of  the  motor  symptoms;  (3)  the 
sequelae,  or  post-epileptic  phenomena;  these  three  groups  in- 
clude the  symptoms  that  are  episodic;  (4)  those  that  are  more 
or  less  constant  during  the  intervals  between  the  attacks  and 
bring  about  anomalies  in  thought  and  action  that  in  a  measure 
show  themselves  in  the  character  of  the  individual.  These  per- 
manent changes  vary  in  degree  from  mere  eccentricities  of  char- 
acter to  the  most  pronounced  forms  of  dementia. 

Before  proceeding  to  the  discussion  of  the  different  groups, 
a  word  may  be  said  in  passing  as  to  the  general  character  of 
the  mental  symptoms.  Thus  we  may  have  forms  characterized 
by  periods  of  (a)  excitement,  (&)  depression,  and  (c)  mixed 
forms,  in  all  of  which  impulses  may  play  an  important  role. 
The  excitement  may  take  the  form  of  simple  mania  lasting  for 
only  a  few  minutes  or  in  some  instances  for  months  or  even 
years,  or  it  may  be  of  extreme  violence  (manie  furieuse). 

The  impulsions  are  characterized  by  their  sudden,  in- 
explicable appearance  and  their  independence  of  external 
circumstances.  They  are  very  varied  in  character, — suicidal, 
homicidal,    dipsomaniacal,    pyromaniacal,    poriomaniacal, — or 


THE   EPILEPSY    GROUP  475 

they  may  be  associated  with  various  forms  of  automatism  and 
exhibitionism. 

(1)  Aura  may  be  classified  as  psychic,  sensorial,  motor, 
and  vasomotor  (Reynolds).  Among  the  more  important  of  the 
disturbances  in  the  mental  activities  are  the  anomalies  of  emo- 
tion. A  patient  may  be  overwhelmed  by  states  of  anxiety 
which  are  intimately  associated  with  changes  in  the  organic 
sensations.  Frequently  he  is  able  to  localize  the  accompanying 
disturbances  in  the  head,  breast,  or  abdomen.  Not  infrequently 
the  onset  of  the  anxiety  is  sudden  and  to  the  patient  inexplica- 
ble, and  at  times  this  sensation  develops  into  a  definite  fear. 
The  former  may  be  accounted  for  in  the  majority  of  cases  by 
the  comparatively  short  duration  of  the  phenomenon,  while  in 
the  cases  in  which  the  aurse  last  longer  anxiety  may  crystallize 
into  a  definite,  well-defined  phobia,  and  when  this  is  the  case, 
in  addition  to  the  changes  in  the  organic  sensations,  hallucina- 
tions and  delusions  may  occur,  which  often  form  the  basis  of 
an  anomalous  affective  state.  Not  uncommonly  the  first 
symptom  of  an  approaching  epileptic  seizure  is  a  profound 
mental  depression,  the  patients  sinking  deeper  and  deeper  into 
the  slough  of  despond  until  they  are  overwhelmed  by  the  seiz- 
ure. Binswanger  reports  an  instance  in  which  the  period  of 
depression  was  followed  by  one  of  marked  exaltation  amount- 
ing to  euphoria.  As  a  rule,  during  the  prodromal  stage  the 
patient  is  apt  to  be  excessively  irritable,  brooks  no  interference ; 
he  is  subject  to  violent  outbursts  of  temper  and  shows  a  high 
degree  of  emotional  instability.  The  disturbances  of  the  intel- 
lectual faculties  are  either  the  result  of  marked  inhibition,  in 
which  case  there  is  complete  interference  with  certain  of  the 
mental  processes,  or  there  may  be  an  apparent  increase  in  the 
intensity  and  rapidity  of  the  psychical  reflexes.  In  the  former 
case  there  is  retardation  and  a  marked  delay  in  the  working  up 
and  elaboration  of  every  stimulus  that  impinges  upon  the  cere- 
bral cortex,  not  only  in  the  sense  areas,  but  the  defects  are  even 
more  general,  including  the  functions  of  associative  memory. 
Sometimes  the  amnesia  amounts  to  a  general  impairment  of 
memory,  while  in  other  instances  it  is  more  localized,  the  defects 


476  PSYCHIATRY 

being  checkered  in  character  and  certain  islands  of  memory 
remaining  intact.  The  patients  frequently  describe  this  tem- 
porary mental  enfeeblement  by  declaring  that  they  have  diffi- 
culty in  thinking,  that  their  thoughts  become  obscure,  that  they 
are  unable  to  direct  their  attention,  and  in  many  ways  appar- 
ently recognize  the  general  sluggishness  of  all  the  cerebral  pro- 
cesses. The  delay  in  the  association  of  ideas  may  be  easily 
shown  by  means  of  the  simple  clinical  tests  to  which  allusion 
is  made  in  the  first  section  of  the  book.  In  the  antithetical  state 
the  mental  reflexes  sometimes  seem  to  be  short-circuited  as  it 
were,  and  there  is  such  a  quick  response  to  any  and  every 
stimulus  that  there  seems  to  be  an  increase  in  the  mentality; 
nevertheless,  on  careful  examination  the  field  of  consciousness 
is  found  to  be  limited,  the  apparent  augmentation  in  the  psychic 
activity  being  merely  due  to  the  promptness  of  the  simpler 
psychic  reaction  and  not  to  any  greater  elaboration  in  the  work- 
ing up  of  the  stimulus. 

Among  the  psychic  aurae  imperative  ideas  and  obsessions 
play  an  important  role.  Patients  not  infrequently  complain  that 
during  a  certain  period  preceding  the  attack  they  are  distressed 
by  the  rapidity  and  intensity  with  which  their  brain  seems  to 
act.  Certain  obsessions  shoot  up  into  the  field  of  consciousness 
and  serve  to  increase  their  nervousness,  sometimes  giving  rise 
to  definite  states  of  anxiety  or  fear.  The  aurae  connected  with 
the  special  senses  are  frequent  and  varied  in  character  (Gow- 
ers).  In  the  visual  field  patients  frequently  suffer  from  ele- 
mentary hallucinations :  they  see  bright  lights,  occasionally 
colored,  particularly  red.  Associated  with  these  elementary 
hallucinations  are  those  of  a  more  complex  character, — visions 
of  animals  or  human  figures.  Not  infrequently  patients  de- 
scribe these  phenomena  with  great  accuracy  and  minuteness. 
As  a  rule,  the  hallucinations  and  delusions  are  grotesque  and 
bizarre  in  character.  The  elementary  auditory  hallucinations 
belong  rather  to  the  more  complex  forms,  which  are  less  fre- 
quently encountered. 

(2)  Mental  Symptoms  occurring  during  the  Height  of  the 
Attack. — Instead  of  the  convulsive  seizures  characterized  by 


THE   EPILEPSY    GROUP  477 

tonic  or  clonic  spasms  with  marked  disturbances  in  conscious- 
ness, there  may  occur  what  are  termed  psychic  equivalent  at- 
tacks. These  may  be  divided  categorically  into  three  groups : 
(a)  transitory  disturbances  in  consciousness,  lasting  for  a  few 
seconds  or  minutes;  (&)  the  same  psychical  defect  associated 
with  slight  motor  involvement,  such  as  turning  of  the  head, 
temporary  squint,  etc.;  (c)  clouding  of  consciousness  asso- 
ciated with  affective  emotional  disorders,  accompanied  by 
anomalous  automatic  impulsive  acts.4 

Frequently  it  is  impossible  to  recognize  with  certainty 
these  transitory  disturbances  as  epileptiform,  and  it  is  only  after 
their  recurrence  and  when  the  probability  of  the  existence  of 
some  organic  brain  lesion  has  been  eliminated  that  the  diag- 
nosis can  be  determined.  There  is  no  form  of  mental  aberra- 
tion which  is  more  commonly  ignored  or  not  recognized  than 
the  milder  types  of  the  psychoses  which  belong  to  latent  epi- 
lepsy, as  it  is  termed  {larvirte  epilepsie).  In  the  less  severe 
forms  of  the  disease — petit  mal  intellectuel — the  patients  not 
infrequently  pass  from  a  period  of  depression  to  one  of  anxiety, 
in  which  they  become  irritable  and  impulsive.  Not  infrequently 
during  these  attacks  the  sufferer  may  even  become  so  desperate 
that  he  attempts  suicide.  As  a  rule,  the  subjects  of  these  at- 
tacks retain  some  insight  into  their  condition,  and  often  rec- 
ognize that  they  are  the  subjects  of  obsessions  or  insane  ideas, 
or  wander  about  aimlessly,  overwhelmed  by  anxiety.  The 
attack  itself  lasts  from  a  few  seconds  to  several  minutes. 

The  more  severe  attack — grand  mal  intellectuel — may 
be  preceded  by  a  period  during  which  the  motor  discharge  is 
replaced  by  severe  emotional  storms,  marked  mental  depres- 
sion, intense  anger,  or  great  anxiety,  associated  with  hallucina- 
tions of  various  forms.  Aschaffenburg  noted  the  occurrence  of 
attacks  of  mental  depression  in  78  per  cent,  of  the  cases  of  psy- 
chic epilepsy.  This  symptom  was  practically  uncomplicated  in 
some  cases,  while  in  others  it  was  associated  with  anxiety,  optic 
hallucinations,  motor  restlessness,  and  boisterous  aggressive- 

4  V.  Krafft-Ebing :   Lehrbuch  der  Psychiatrie,  7te  Auflage,  1903,  S.  486. 


478  PSYCHIATRY 

ness.  Frequently  the  diagnosis  is  only  possible  when  the  attack 
has  passed  and  the  patient  falls  into  a  deep  sleep.  Often 
there  is  a  period  preceding  the  acme  which  is  characterized 
by  primary  incoherence  and  marked  dissociation  of  thought, 
while  in  other  instances  there  may  be  stupor,  broken  by  periods 
of  intense  excitement,  during  which  the  conduct  of  the  patient 
is  dictated  by  obsessions  and  impulses  of  such  a  dominating 
character  that  the  individual  brooks  no  interference,  destroys 
his  clothing,  breaks  the  furniture,  rushes  heedlessly  about,  in- 
jures those  who  come  across  his  path,  and  becomes  a  source 
of  the  greatest  danger  not  only  to  himself,  but  to  those  about 
him.  It  is  not  improbable  that  a  symptom-complex  that  in 
some  measure  suggests  the  typical  flight  of  ideas  as  seen  in 
manic  excitement  may  be  occasionally  noted  in  these  transitory- 
periods  of  aberration  occurring  in  epileptics.5  As  a  rule,  the 
excessive  narrowing  in  the  field  of  consciousness  with  the  ten- 
dency to  verbigeration,  as  well  as  the  boisterous  rage  of  the 
epileptic,  serve  to  distinguish  this  apparent  fictitious  flight  from 
that  seen  in  manic-depressive  states.  It  is  only  in  those  cases 
of  epileptic  mania  in  which  the  motor  restlessness  is  excessive 
and  the  emotional  storm  is  very  intense  that  this  apparent  flight 
really  resembles  the  true  maniacal  type. 

In  some  instances  speech  compulsion  and  verbigeration  rap- 
idly alternate  with  periods  of  mutism,  a  combination  of  symp- 
toms that  is  somewhat  analogous  to  conditions  that  are  marked 
in  hysteria  and  in  precocious  dements. 

Orientation,  as  would  be  expected,  is  markedly  impaired. 
The  hallucinations  vary  greatly  in  number  and  intensity.  As 
a  rule,  the  visual  and  auditory  predominate,  but  the  functions 
of  touch,  taste,  and  smell  may  be  similarly  affected.  The  pa- 
tient's relation  to  the  external  world  is  almost  completely  sev- 
ered, and  definite  motives  for  action  are  replaced  by  obsessions 
and  fallacious  sense  perceptions,  which,  as  a  rule,  take  on  great 
sensory  vividness  and  a  variety  of  forms. 


5  Heilbronner :    Ueber  epileptische  Manie  nebst  Bemerkungen  iiber  die 
Ideenflucht. 


THE   EPILEPSY    GROUP  479 

Especially  common  are  grotesque  or  frightful  apparitions, 
whose  approach  overwhelms  the  patient  with  fear  and  intense 
anxiety, — curious  animals,  monsters  of  all  sorts,  devils,  fright- 
ful-looking personages,  who  attempt  murder,  rape,  etc.  Not 
infrequently  the  fallacious  sense  perceptions  are  so  vivid  and 
of  such  a  gruesome  and  terrifying  character  as  to  give  rise  to 
states  of  intense  mental  anguish.  Patients  are  threatened  by 
some  dreadful  incubus,  are  confronted  by  the  tortures  of  hell, 
see  visions  and  dream  dreams  more  terrible  in  their  content 
than  the  sights  described  in  the  Inferno.  Sometimes  the  visions 
are  of  a  different  character.  Devils  are  replaced  by  angels, 
the  patients  have  communication  with  heaven,  and,  as  a  result 
of  these  pleasant  revelations,  marked  euphoria  may  be  present, 
the  patients  giving  expression  to  their  feelings  by  jubilant 
shouts  or  by  decking  themselves  in  fancy  dress.  The  allopsy- 
chic disorientation  of  the  patient  in  cases  of  this  character  may 
in  part  be  referable  to  hallucinations  and  delusions,  but  there 
are  others  where  this  sensory  vividness  is  less  intense,  and  then 
the  disorientation  is  due  to  other  causes. 

As  a  rule,  the  number  of  representations  in  consciousness 
is  decidedly  limited.  This  in  a  measure  undoubtedly  explains 
the  intensity  of  certain  retained  sensations  and  the  reflex  effect 
which  they  seem  to  exert  on  the  conduct  of  the  individual.  In 
these  severe  cases  the  memory,  as  may  be  inferred,  is  markedly 
impaired,  although  occasionally  single  and  isolated  events  that 
occur  during  the  attack  are  remembered. 

Essentially  characteristic  of  psychic  epilepsy  is  the  so- 
called  dream  state,  in  which  we  see  evidences  of  considerable 
interference  with  the  cortical  functions,  and  this  in  turn  is  a 
potent  factor  in  the  production  of  the  allopsychic  disorientation. 
As  Wernicke  has  pointed  out,6  the  disorientation  may  be  so 
excessive  as  to  amount  to  asymbolism. 

A  second  important  characteristic  of  the  dream  state  is 
the  tendency  shown  by  certain  cortical  functions  when  once 
initiated  to  persevere    (perseveration).      Patients   repeat  the 

6  Op.  cit. 


480  PSYCHIATRY 

same  words  in  reply  to  widely  different  questions,  and  it  is  fre- 
quently necessary  to  greatly  increase  the  intensity  of  the  audi- 
tory stimulus  before  a  change  in  the  reply  is  given.  This  ten- 
dency is  also  shown  in  the  repetition  of  certain  acts  and  in  the 
recurrence  and  persistence  of  certain  ideas  or  groups  of  ideas. 

(3)  The  post-epileptic  mental  disturbances  may  in  a  meas- 
ure resemble  those  which  precede  the  attack.  In  some  instances 
they  may  be  regarded  as  merely  protracted  aurse  or  as  ante- 
cedents of  the  stuporous  state.  Just  as  in  the  period  preceding 
the  attack,  so  following  it,  we  may  have  marked  emotional 
disturbances,  pronounced  anxiety,  psychomotor  retardation, 
periods  characterized  by  hallucinosis  and  the  cropping  up  of  im- 
perative ideas  and  obsessions.  In  this  period  there  may  also 
be  various  degrees  of  mental  apathy,  with  or  without  the  au- 
tomatic and  impulsive  acts.  At  times  there  occur  the  well- 
known  dream-like  states,  lasting  from  a  few  seconds  to  several 
hours,  days,  or  even  weeks,  or  periods  of  marked  excitement, 
with  vivid  and  persistent  hallucinations  and  very  great  incoher- 
ence, similar  to  those  already  described  may  intervene.  The 
protracted  stuporous  states  are  much  more  common  at  this 
time  than  in  the  initial  stage  or  during  the  so-called  equivalent 
period.  Associated  with  the  impaired  mentality  there  may  at 
times  be  marked  mutism  during  which  the  loss  of  consciousness 
is  only  partial.  Not  infrequently  cataleptic  phenomena  are 
noted,  and  these  may  give  rise  to  great  difficulty  in  differentiat- 
ing the  case  from  one  of  dementia  prsecox.  It  should  not  be 
forgotten  that  the  post-epileptic  mental  disturbance  sometimes 
follows  single  and  ill-defined  attacks  or  recurs  only  after  the 
lapse  of  long  intervals.  When  this  is  the  case  there  is  naturally 
great  difficulty  in  establishing  the  diagnosis.  Occasionally  an 
abortive  epileptiform  attack  is  followed  by  marked  disturbances 
in  consciousness  and  considerable  amnesia,  a  condition  that 
may  give  rise  to  questions  of  great  forensic  importance.  The 
duration  of  unconsciousness,  both  during  the  attack  itself  and 
in  the  terminal  stage,  varies  greatly.  In  some  instances  the 
period  of  total  amnesia  is  synchronous  with  that  of  the  stupor 
or  coma,  while  in  others  the  patient's  memory  may  be  so  de- 


THE   EPILEPSY    GROUP  481 

fective  as  to  be  a  perfect  blank,  not  only  for  all  events  during 
the  height  of  the  attack,  but  for  a  considerable  period  prior 
to  the  onset  of  the  first  pronounced  symptoms.  In  these  cases 
the  post-epileptic  stage  can  not  be  well  differentiated  from  the 
equivalent  period.  Thus  one  of  my  patients  remembered  dis- 
tinctly leaving  his  home  on  a  certain  morning  to  go  to  his  place 
of  business.  He  had  not  proceeded  far  when  he  suddenly  lost 
consciousness,  and  when  he  regained  it  he  found  himself  under 
arrest,  accused  of  having  broken  a  large  plate-glass  window  in 
a  store  at  some  distance  from  the  spot  where  he  lost  conscious- 
ness. 

The  forensic  importance  of  similar  attacks  is  very  great. 
Patients  often  become  violent,  brutal,  and,  on  account  of  their 
recklessness  and  apparent  indifference  to  pain,  can  be  restrained 
only  by  the  exercise  of  great  force.  Siemerling  reports  the 
case  of  a  patient  who,  during  an  attack  characterized  by  great 
excitement  and  confusion,  with  marked  automatic  impulsive 
acts,  had  once  been  confined  in  a  hospital  for  the  insane.  Three 
years  later,  without  any  apparent  motive,  this  same  man  killed 
a  woman.  Witnesses  to  the  act  immediately  took  the  man  into 
custody.  During  the  examination  that  followed  the  patient 
remained  perfectly  quiet,  showed  no  appreciation  of  the  deed, 
and  made  no  attempt  to  escape.  Gradually  he  awakened  from 
the  dream-like  state  into  which  he  had  fallen,  and  at  first 
affirmed  that  he  had  not  committed  any  crime,  but  finally  ad- 
mitted the  commission  of  the  deed,  justifying  it,  however,  on 
the  ground  that  it  was  done  in  response  to  a  command  of  God. 
During  the  six  weeks  in  which  he  was  under  observation  in  the 
Charite  the  patient  suffered  from  transitory  disturbances  of 
consciousness,  with  hallucinations  associated  with  marked 
periods  of  anxiety.  The  memory  was  exceedingly  defective. 
When  the  attack  finally  subsided  the  patient  affirmed  that  on  the 
day  on  which  he  had  committed  the  murder  he  remembered 
having  had  a  severe  headache  and  the  sudden  and  inexplicable 
appearance  of  the  idea  that  he  must  immediately  buy  a  razor. 
On  the  evening  of  the  same  day  he  went  to  Berlin  to  visit  his 
brother.     Soon  after  arriving  in  the  city  his  memory  became  a 

31 


482  PSYCHIATRY 

perfect  blank,  with  the  exception  that  he  vaguely  remembered 
attacking  some  person,  being  actuated  only  by  a  blind  impulse. 
This  is  an  example  of  a  group  of  cases  that  not  infrequently 
come  under  observation.  Patients  of  this  class  during  these 
periods  of  unconsciousness  (ambulatory  automatism)  have 
been  known  to  go  on  long  journeys,  to  commit  theft,  arson,  or 
assault,  and  display  a  marked  tendency  to  exhibitionism  and 
vagabondage. 

Buchholtz  called  attention  to  a  comparatively  small  group 
of  cases  in  which  the  insane  ideas  develop  during  the  equivalent 
period,  become  systematized,  and  persist  for  long  periods  of 
time.  These  are  the  instances  referred  to  in  the  literature  as 
paranoiic  states  developing  upon  an  epileptic  basis. 

(4)  In  the  majority  of  cases  after  the  epilepsy  has  existed 
for  a  considerable  period  of  time  a  more  or  less  pronounced 
form  of  dementia  makes  its  appearance.  Gradually  the  interests 
of  the  individual  become  more  or  less  limited  and  monotonous. 
The  mental  processes  are  considerably  delayed,  marked  length- 
ening in  the  reaction  time  taking  place.  The  defects  in  memory 
become  more  noticeable,  and  the  intellectual  and  ethical  deficien- 
cies are  so  intensified  that  finally  in  the  severest  forms  of  the 
disease  the  patients  are  unable  to  show  any  evidence  of  cerebra- 
tion. In  these  cases  the  articulation  of  speech  may  be  seriously 
impaired,  and  the  individual  is  reduced  to  a  state  which  is  com- 
parable to  some  of  the  lowest  forms  of  idiocy.  The  earlier  in 
life  the  epileptic  attacks  appear,  the  more  apt  is  the  dementia  to 
become  of  a  pronounced  character. 

Differential  Diagnosis. — As  has  already  been  pointed 
out,  there  is  often  great  difficulty  in  distinguishing  mental  dis- 
orders associated  with  epilepsy  from  those  occurring  during 
the  course  of  other  psychoses.  This  is  particularly  true  in  re- 
gard to  the  various  forms  of  hysteria.  It  should  also  be 
remembered  that  hysterical  symptoms  may  obscure  those  of 
genuine   epilepsy.7      Sufficient  has  already  been   said   in  the 

7  Hermann,  J.  S. :  Ueber  spatauftretende  hysterische  Anfalle  bei  Epi- 
leptikern.  Monatsschr.  f.  Psych,  u.  Neurol.,  xiii.  Bratz  u.  Falkenberg: 
Hysterie  und  Epilepsie.  Archiv  f.  Psych.,  Bd.  xxxviii,  Hft.  2,  1904. 


THE   EPILEPSY    GROUP  483 

chapter  on  hysteria  to  point  out  the  symptoms  that  may  be 
considered  of  importance  in  differentiating  the  two  diseases. 
The  vertigo  without  disturbances  in  consciousness,  which  fre- 
quently occurs  in  patients  suffering  from  gastric  or  cardiac  dis- 
ease, is  easily  differentiated  from  true  attacks  of  epilepsy.  In 
the  prodromal  stage  of  dementia  paralytica,  the  senile  psy- 
choses, or  during  the  onset  of  the  acute  delirium,  we  not 
infrequently  meet  with  states  of  apprehensiveness,  motor  rest- 
lessness, irritability  associated  with  visual  and  auditory  hallu- 
cinations, combined  with  outbreaks  of  anger  and  suicidal  or 
homicidal  attempts,  which  may  temporarily  resemble  epilepti- 
form attacks.  The  subsequent  development  of  the  case,  as  well 
as  the  characteristic  visual  symptoms  in  a  case  of  paresis,  aid 
in  establishing  a  diagnosis.  Not  infrequently  in  individuals 
who  are  afflicted  with  gout  we  meet  with  epileptiform  attacks 
which  present  many  difficulties  in  the  differentiation  from  true 
epilepsy,  but  in  the  former  the  prognosis  is  very  much  better 
than  in  cases  in  which  we  have  the  hallucinations,  the  impulsive 
acts,  and  the  memory  disturbances  described  as  characteristic 
of  the  confusional  states  occurring  during  epilepsy.  Some 
observers  affirm  that  the  more  or  less  sudden  onset  and  disap- 
pearance of  alienation,  the  peculiar  type  of  the  hallucinations, 
the  impulsive  acts,  and  the  memory  defects  should  at  once 
arouse  suspicions  as  to  the  existence  of  this  malady.  Others 
maintain  that  if  epilepsy  is  present  the  insane  ideas  are  either 
of  a  persecutory  or  boastful  character  and  that  the  hallucina- 
tions generally  refer  to  religious  subjects.  Kraepelin,  on  the 
other  hand,  has  emphasized  the  apprehensive,  angry  character 
of  the  patients  suffering  from  epileptic  mania,  while  Bon- 
hoeffer  thinks  that  a  hypochondriacal  coloring  of  the  insane 
ideas  with  marked  disturbances  of  organic  sensations  and 
hallucinations  of  smell  and  taste  are  alone  specific.  The 
attempt  to  establish  a  safe  criterion  based  upon  the  analysis  of 
the  physical  symptoms  is  equally  unsatisfactory.  The  absence 
of  the  light  reflex,  which  sometimes  occurs  and  may  persist  for 
twenty-four  hours,  is  frequently  noticed  in  other  conditions. 
Probably  somewhat  more  important  are  the  dilated  pupils  with 


484  PSYCHIATRY 

a  sluggish  reaction  for  light.  It  is  not  improbable,  as  Raecke 
and  others  have  pointed  out,  that  the  drunken  character  of  the 
walk,  the  general  tremor  and  irregular  incoordinated  move- 
ments, reminding  one  of  chorea  or  myoclonia,  deserve  more 
careful  attention.  The  speech  disturbances,  including  either 
marked  disturbance  of  articulation  with  a  tendency  to  scan  and 
stammer,  and  in  other  instances  pronounced  aphasic  symptoms, 
with  echolalia  and  verbigeration,  have  received  careful  study. 
Pick8  has  indicated  the  sequence  of  what  he  calls  the  re-evolu- 
tion of  speech  following  the  epileptic  attack.  At  first  there  is 
complete  word  deafness,  and  then,  although  the  patient  is 
unable  to  comprehend  the  sense  of  the  words,  he  can  repeat 
them  mechanically.  This  period  is  followed  at  varying 
intervals  by  the  return  of  spontaneous  speech. 

Frequently,  if  no  history  of  the  patient  has  been  obtained, 
there  is  some  difficulty  in  deciding  whether  a  case  is  one  of 
manic-depressive  insanity  or  the  mania  of  epilepsy.  Formerly 
it  was  believed  that  the  typical  flight  of  ideas  was  charac- 
teristic solely  of  the  excited  periods  of  manic-depressive  in- 
sanity, but  recently  Heilbronner9  has  called  attention  to  the 
fact  that  a  syndrome  closely  resembling  this  may  occur  in  true 
epileptic  mania.  The  differential  diagnosis  may  be  still  further 
complicated  by  the  appearance  of  euphoria,  distractibility,  mo- 
tor restlessness,  and  speech  compulsion.  We  believe,  however, 
that  this  combination  of  symptoms  is  of  comparatively  infre- 
quent occurrence,  and  such  a  condition  is  apt  to  persist  only  in 
cases  of  true  mania.  The  differential  diagnosis  is  sometimes 
difficult  to  make  from  cases  of  true  mania  where  the  patient 
is  exceedingly  aggressive,  boisterous,  and  brutal.  As  a  rule, 
the  epileptic  characteristics,  such  as  marked  apprehensiveness, 
states  of  ecstasy,  and  acts  which  are  the  result  of  blind  im- 
pulses,  sooner  or  later  become  so  prominent  in  the  clinical 

8  Ueber  die  sogen.  Reevolution  (H.  Jackson)  nach  epileptischen  An- 
fallen  nebst  Bemerkungen  iiber  transitorische  Worttaubheit.  Arch.  f. 
Psych.,  xxii,  S.  756. 

9  Heilbronner,  Karl :  Ueber  epileptische  Mania  nebst  Bemerkungen 
-iiber  die  Ideenflucht.    Monatsschr.  f.  Psych,  u.  Neurol.,  xiii. 


THE   EPILEPSY    GROUP  485 

picture  as  to  be  easily  recognized.  Sometimes  patients  suffer- 
ing from  catatonic  excitement  may  suggest  the  various  forms 
of  epileptic  mania.  The  differentiation  is  frequently  compli- 
cated by  the  appearance  of  perseveration.  This  symptom, 
which  frequently  occurs  in  cases  of  dementia  prsecox,  is  also 
common  in  epilepsy.  Bonhoeffer10  has  shown  that  the  capa- 
city of  epileptics  for  association  is  particularly  limited,  and 
that  in  addition  to  this  they  show  a  marked  inclination  to  re- 
peat certain  words.  On  this  account  the  speech  of  patients 
may  be  particularly  monotonous,  and  they  may  repeat  for 
hours  at  a  time  certain  phrases  or  words.  The  importance 
of  these  senseless  repetitions  in  epileptic  states  has  been  em- 
phasized by  Siemerling.11  But  the  appearance  of  mannerisms, 
stereotypies,  negativism,  as  a  rule,  establish  the  diagnosis. 

Recently  Raecke 12  has  carefully  studied  the  transitory 
disturbances  in  consciousness  in  epileptics  with  a  view  to  de- 
termining, if  possible,  whether  any  causal  relationship  exists 
between  these  and  the  convulsive  seizures.  As  the  result  of 
his  observations,  he  has  come  to  the  conclusion  that  the  ethical 
and  intellectual  defects  in  epilepsy  do  not  develop  in  proportion 
to  the  severity  and  duration  of  the  attacks,  although  both 
phenomena  are  undoubtedly  the  result  of  similar  disturbances  in 
the  cortical  functions.  The  variety  of  the  attacks  may  be  differ- 
entiated according  to  their  severity  as  follows : 

(1)  The  severe  convulsive  attacks;  (2)  the  rudimentary 
and  atypical  seizures;  (3)  petit  mal;  (4)  states  of  confusion; 
(5)  paranoiic  conditions;  (6)  the  dream  states,  and  finally  the 
periods  of  depression  or  exaltation.  Gradually  clinicians  have 
come  to  realize  that  the  amnesia  is  not  a  safe  criterion  in  the 
absence  of  other  symptoms  upon  which  the  diagnosis  of  psychic 
epilepsy  may  be  made.  Amnesic  defects  may  be  absent  in  epi- 
leptiform attacks,  but  when  they  exist  may  present  a  variety 

10  Die  akuten  Geistesstorungen  der  Gewohnheitstrinker.     Jena,  1901. 

11  Ueber  die  transitorischen  Bewusstseinsstorungen  der  Epileptiker  in 
forensischer  Beziehung.     Berl.  klin.  Wchnschr.,  1895,  Nr.  12. 

12  Die  transitorischen   Bewusstseinsstorungen   der   Epileptiker.     Halle 
a/S.,  1903. 


486  PSYCHIATRY 

of  forms.  The  onset  is  sudden,  and  the  return  of  the  power 
to  re-collect  and  redevelop  past  impressions  may  be  equally 
abrupt.  The  amnesic  defect,  as  a  rule,  has  the  following 
characteristics :  It  may  be  simple,  retrograde,  anterograde, 
transitory  or  permanent,  complete  or  incomplete,  or  may  be 
entirely  absent.  Its  presence  may  justify  the  suspicion  of  the 
existence  of  epilepsy,  but  its  absence  is  not  proof  positive  that 
the  disease  does  not  exist.  The  simple  and  retrograde  am- 
nesia may  not  render  an  individual  irresponsible  for  all  his  acts, 
and  in  this  way  is  essentially  different  from  the  anterograde 
form.13 

Pathogenesis. — The  so-called  hereditary  factor  in  cases 
of  epilepsy  is  of  great  etiological  importance.  Griesinger  was 
among  the  first  to  call  attention  to  the  neuropathic  or  psycho- 
pathic predisposition  that  exists  in  many  cases,  and  clinical 
observation  has  shown  that  in  individuals  in  whom  this 
psychopathy  is  marked  there  is  an  apparent  lowering  of  the 
resistance  of  the  central  nervous  system  for  both  physiological 
and  pathological  stimuli.  As  yet  nothing  definite  is  known 
in  regard  to  the  primary  changes  in  function  which  form 
the  basis  upon  which  this  condition  develops.  As  the  result 
of  clinical  study,  we  know  that  the  causes  producing  this  pre- 
disposition may  act  through  one  or  both  parents  upon  the 
child;  they  may  be  acquired  during  intra-uterine  life,  or  after 
birth. 

In  the  first  category  may  be  grouped  all  the  agencies  which 
have  such  a  deleterious  effect  upon  the  ancestry  as  to  give  rise 
to  anomalies  of  function  in  the  nervous  system  of  the  descend- 
ants. Chief  among  these  is  alcohol.  It  is  affirmed  that  in  at 
least  one-quarter  of  the  cases  of  epilepsy  the  history  of  alcohol- 
ism in  one  or  both  parents  may  be  obtained,  and  not  only  is 
this  poison  responsible  for  many  of  the  cases  of  pure  functional 
epilepsy,  but  it  is  also  an  etiological  factor  of  great  importance 
in  cases  of  imbecility  and  idiocy  with  epileptiform  seizures. 


13  Maxwell,  J. :    L'amnesie  et  les  troubles  de  la  conscience  dans  l'epi- 
lepsie.    Leipzig,  1903. 


THE   EPILEPSY    GROUP  487 

Robinovitch 14  has  endeavored  to  demonstrate  the  apparent 
definite  causal  connection  that  exists  between  this  psychosis  and 
various  forms  of  ancestral  alcoholism.  Nevertheless,  while  it 
is  only  right  to  be  exceedingly  cautious  in  minimizing  the  im- 
portance of  this  drug  as  an  etiological  factor,  the  fact  must  be 
kept  in  mind  that  the  existing  evidence  does  not  fully  justify 
the  statements  so  frequently  made  to  the  effect  that  there  is  an 
immediate  causal  connection  between  the  occurrence  of  alco- 
holism in  a  remote  ancestor  and  of  epilepsy  in  the  individuals 
of  a  later  generation.  Many  of  the  agencies  that  interfere 
with  normal  conception  and  pregnancy  may  result  in  the  birth 
of  epileptic  children.  In  this  category  may  be  enumerated  psy- 
chic shocks,  trauma,  as  well  as  the  various  accidents  incident  to 
pregnancy  and  parturition. 

In  addition  to  the  deleterious  effects  upon  the  offspring  of 
chronic  alcoholism  in  the  parents,  it  is  well  known  that  lead, 
morphin,  etc.,  may  be  equally  important  factors  in  the  produc- 
tion of  epileptic  children.  A  similar  tendency  exists  if  the  par- 
ents suffer  from  general  constitutional  diseases,  such  as 
tuberculosis,  syphilis,  as  well  as  profound  anaemia,  leukaemia, 
diabetes,  gout.  In  such  cases  the  children  may  suffer  from  a 
general  impairment  of  the  functions  of  the  central  nervous  sys- 
tem or  from  marked  developmental  anomalies  of  structure  and 
subsequent  impairment  in  function. 

The  deductions  derived  from  careful  clinical  observation 
all  tend  to  support  the  view  that  epilepsy  is  to  be  considered  not 
as  the  immediate  effect  of  the  deleterious  action  of  the  agencies 
already  described,  but  rather  as  an  expression  of  a  certain  es- 
tablished predisposition,  and  the  same  factors  which  may  have 
been  potent  in  the  production  of  the  tendency  of  an  individual 
to  nervous  or  mental  disease  may  also  become  important  etio- 
logical factors  immediately  operative  during  his  life.  This  is 
particularly  true  in  regard  to  the  various  forms  of  intoxication 
to  which  reference  has  already  been  made.    Alcohol,  lead,  mor- 


14  Robinovitch,  Louise  G. :     The  Genesis  of  Epilepsy.     The  Journal  of 
Mental  Pathology,  1902. 


488  PSYCHIATRY 

phin,  may  all  play  an  important  role.  The  same  is  true  in 
regard  to  the  effect  of  exhaustion.  Excessive  mental  or  physi- 
cal strain  may  have  an  injurious  influence  upon  the  central 
nervous  system.  The  chronic  constitutional  diseases  of  child- 
hood, such  as  rachitis  and  scrofula,  are  also  of  importance,  as 
well  as  the  diseases  which  develop  later  in  life,  particularly  at 
the  time  of  puberty,  such  as  the  severe  forms  of  anaemia,  the 
hemorrhagic  diathesis,  scurvy,  hemophilia,  gout,  arthritis  de- 
formans, diabetes  mellitus.  The  relation  of  the  acute  infectious 
diseases  to  this  psychosis  has  been  repeatedly  emphasized  by 
clinicians — measles,  diphtheria,  typhoid,  as  well  as  whooping- 
cough,  scarlet  fever,  and  malaria. 

That  a  connection  exists  between  syphilis  and  epilepsy  has 
long  been  recognized.  The  cases  of  functional  epilepsy  which 
develop  in  individuals  who  have  had  a  syphilitic  affection  are 
to  be  differentiated  from  those  in  which  the  convulsive  seizures 
are  merely  the  early  symptoms  of  marked  structural  lesions  due 
to  the  specific  toxin.  Long  ago  Fournier  called  attention  to 
the  fact  that  the  primary  infection  might  become  an  etiologic 
factor  of  great  importance  in  the  pathogenesis  of  cases  of  epi- 
lepsy. Parasyphilitic  epilepsy  often  occurs  in  individuals  in 
whom  the  primary  infection  has  taken  place  years  before  the  ap- 
pearance of  the  convulsive  disease.15  The  attacks,  as  a  rule,  ap- 
pear less  often  than  in  the  so-called  idiopathic  forms  of  the  dis- 
ease, but  the  dream-like  states  are  comparatively  more  frequent, 
while  the  intellectual  defects  are  less  common.  The  fact  should 
be  borne  in  mind  that  the  specific  infection  cannot  be  justly  re- 
garded as  the  prime  cause  of  epilepsy  if  a  definite  history  of  the 
action  of  other  injurious  agencies,  such,  for  example,  as 
trauma,  alcoholism,  severe  attacks  of  the  acute  infectious  dis- 
eases, cardiac  lesions,  arterio-sclerosis,  diabetes  mellitus,  has 
been  obtained.  The  causal  relationship  between  epilepsy  and 
syphilitic  infection  has  been  referred  by  some  clinicians  to  the 
so-called  dyscrasia,  by  others  to  the  changes  in  metabolism 
caused  by  the  action  of  the  syphilitic  poison,  or,  finally,  to  the 

15  Syphilis  und  Nervensystem.     Max  Nonne.     Berlin,  1902. 


THE   EPILEPSY    GROUP  489 

lesions  in  the  central  nervous  system  analogous  to  those  that 
occur  early  in  the  infection  in  the  mucous  membranes  and  skin. 

Paris  16  has  suggested  the  following  purely  hypothetical 
explanation  of  the  malady :  A  hyperactivity  of  the  central  ner- 
vous system  due  primarily  to  an  increase  in  the  secretion  of  the 
thyroid  and  genital  organs  develops,  and  associated  with  this 
there  is  an  accumulation  of  toxins  in  the  blood  due  to  a 
diminution  in  the  excretive  activity.  The  basis  for  such  an 
assumption  rests  largely  on  those  observations  which  tend  to 
show  that  epilepsy  is  more  common  in  women  than  in  men,  and 
also  that  many  cases  of  this  disorder  frequently  seem  to  be 
temporarily  benefited  by  marriage  and  pregnancy.  The  indi- 
cations for  treatment  based  upon  this  theory  are :  ( 1 )  to  at- 
tempt to  diminish  the  general  sensibility;  (2)  to  try  to  limit 
the  functional  activity  of  the  thyroid  and  genital  glands;  (3) 
to  secure  elimination  of  the  secretions,  and,  finally,  to  prevent 
as  far  as  possible  the  accumulation  in  the  organism  of  all  tox- 
ins which  may  serve  to  increase  the  meningo-encephalitic  ex- 
citement. 

Treatment. — The  prevention  of  the  spread  of  this  dis- 
ease is  of  the  greatest  importance.  In  addition  to  the  attempt 
to  mitigate  or  remove  the  causes  referred  to  as  of  etiological 
value,  the  physician  should  do  all  in  his  power  to  prevent  the 
marriage  of  an  individual  who  has  been  afflicted  with  genu- 
ine epilepsy.  There  is  no  form  of  mental  disease  in  which 
there  is  greater  danger  of  either  the  recurrence  of  this  malady 
or  of  the  appearance  of  a  new  psychosis  in  the  descendants. 

During  the  periods  of  depression  and  excitement  the  pa- 
tients are  much  better  off  in  an  institution,  where  they  can  be 
under  constant  medical  supervision  and  receive  careful  nursing. 
Sufficient  has  been  said  to  show  that  these  individuals  may  be  a 
source  of  great  danger,  not  only  to  themselves  but  to  the  com- 
munity, and  therefore  for  their  own  sakes,  as  well  as  for  the 
well-being  of  others,  they  should  be  placed  in  a  hospital  as  soon 
as  the  first  symptoms  of  marked  alienation  are  recognized.  Fre- 

16  Arch,  de  Neurologie,  1904,  Nos.  98-99. 


490  PSYCHIATRY 

quently  a  great  deal  may  be  accomplished  by  the  dietetic  treat- 
ment. The  patient  should  be  taught  to  eat  slowly,  and  in  order 
that  he  may  not  overburden  his  stomach  should  be  allowed  to 
take  small  quantities  of  food  repeated  at  intervals  of  three  or 
four  hours  instead  of  three  meals  a  day.  All  forms  of  stimu- 
lants are  prohibited.  Alcohol  in  any  form  is  a  poison,  and  the 
same  is  true  to  a  less  extent  of  tea  and  coffee.  Tobacco  should 
also  be  withdrawn.  As  a  general  rule,  the  amount  of  butcher's 
meat  should  be  restricted,  chicken,  fish,  oysters,  and  milk  tak- 
ing its  place.  Fresh  bread,  pastry,  and  sweets  are  strongly 
contraindicated.  In  the  severer  cases  an  exclusively  milk 
diet  continued  for  some  time  will  prove  satisfactory.  Not 
infrequently  if  the  dementia  is  not  marked  and  the  periods 
of  excitement  and  depression  are  not  excessive  the  patients 
do  exceedingly  well  in  country  homes  under  medical  super- 
vision where  they  can  be  cared  for  under  the  colony  system. 
Although  the  use  of  the  bromides  is  generally  indicated  dur- 
ing the  periods  of  excitement,  much  may  be  done  to  quiet 
the  patient  by  restricting  the  diet  and  by  giving  wet  packs  or 
the  continuous  bath.  Sedative  drugs  are  far  less  efficacious 
in  the  treatment  of  the  various  forms  of  aberration  associated 
with  epilepsy  than  they  are  in  controlling  the  attacks  associated 
with  convulsive  seizures.  The  bromides  may  be  administered 
in  the  form  of  the  sodium,  potassium,  or  ammonium  salt,  pre- 
ferably alone  or  in  combination.  Care  should  be  exercised  to 
avoid  bromism,  which  is  generally  accompanied  by  marked  loss 
of  appetite,  disturbances  in  the  gastro-intestinal  tract,  acne, 
diminution  in  the  reflexes,  impairment  of  memory,  and  apathy. 
Arsenic  is  frequently  of  use  in  combating  these  symptoms,  and 
in  addition  is  an  excellent  tonic.  Bromalin  (Merck),  bromo- 
pin,  and  bromocol  have  been  recommended  by  various  author- 
ities. Flechsig  advises  the  bromide-opium  treatment.  He  gives 
extract  of  opium,  beginning  with  small  doses,  the  quantity 
being  gradually  increased  until  the  end  of  the  sixth  or  seventh 
week,  when  the  opium  is  suddenly  withdrawn  and  is  replaced 
by  bromide.  Toulouse  and  Richet  have  endeavored  to  bring 
about  what  they  term  a  "  hypochlorization"  of  the  body  in 


THE   EPILEPSY    GROUP  491 

order  to  facilitate  the  absorption  of  the  bromide.  The  daily  diet 
is  as  follows :  1  to  1  ]/2  litres  of  milk,  40  to  50  grammes  of  butter, 
3  eggs  without  salt,  fruit,  300  to  400  grammes  of  white  bread. 
Instead  of  common  salt  the  patient  is  given  three  grammes  of 
sodium  bromide  a  day.  This  procedure  seems  to  have  been  fol- 
lowed with  some  success.  Ceni 17  believed  that  he  had  isolated 
two  specific  substances  in  the  blood  of  epileptics  and  that  he 
had  obtained  beneficial  results  in  the  line  of  treatment  by  em- 
ploying an  artificial  serum  in  which  one  of  these  substances  was 
present.  These  results  have  not  been  generally  confirmed.18 
Decided  improvement  has  been  noted  in  some  cases  after  the 
employment  of  hydrotherapeutic  measures.  Cool  applications 
to  the  head  and  back  as  well  as  half-baths  (at  300 — 260)  given 
for  six  to  ten  minutes  are  the  means  employed.  This  treat- 
ment makes  it  possible  to  greatly  reduce  the  quantity  of 
bromide.  It  is  also  desirable  that  patients  should  drink  plenty 
of  water  so  as  to  aid  in  diuresis. 

The  Pathology  of  Epilepsy. — In  many  of  the  cases  of 
epilepsy,  particularly  those  in  which  the  mental  symptoms  are 
more  prominent  than  the  localized  motor  disturbances,  it  is  im- 
possible to  discover  any  changes  in  the  brain  tissue  which  are  in 
any  sense  pathognomonic.  The  cases  of  Jacksonian  epilepsy 
which  depend  upon  the  existence  of  a  local  lesion  are  rather  of 
neurological  than  of  psychiatrical  interest.  These  include  the 
cases  secondary  to  cerebral  hemorrhage,  trauma,  brain  abscess, 
tumors,  embolism,  thrombosis,  etc.  The  importance  of  the  scar 
tissue  in  the  brain  as  a  source  of  local  irritation,  which  may 
give  rise  to  periods  of  mental  aberration,  offers  a  problem  that 
has  not  as  yet  passed  the  hypothetical  stage,  and  sufficient  ref- 
erence to  this  subject  has  already  been  made  in  the  chapter  on 


17  Del  siero  di  sangue  degli  epilettici.  Riv.  sper.  freniatr.,  vol.  xxvii, 
fasc  iii-iv.  Specifische  Autocytotoxine  u.  Antiautocytotoxine  im  Blute 
der  Epileptiker.  Neurolog.  Centralblatt,  April  16,  1903. 

18  Roncoroni :  La,  sierterapia  dell'  epilepsia.  Archiv  du  psichiat. 
scienze  penali  ed  antropol.  crim.,  vol.  xxiii,  fasc.  4/5,  1902.  Sala  u.  Rossi : 
Zur  Frage  iiber  einige  angebliche  toxische  u.  therapeutische  Eigenschaften 
des  Blut-serums  vom  Epileptikern.     Neurolog.  Centralblatt,  Sept.  15,  1903. 


492  PSYCHIATRY 

manic-depressive  insanity.  That  more  diffuse  lesions  in  the 
central  nervous  system  are  apt  to  give  rise  to  epileptic  seizures 
is  generally  recognized.  The  various  clinical  forms  of  epilepsy 
may  follow  the  acute  meningitides,  both  the  purulent  and  also 
the  serous  varieties,  while  not  infrequently  epilepsy,  compli- 
cated by  a  slow  progressive  dementia,  develops  as  a  sequel  to 
these  inflammations  of  the  membranes. 

Not  infrequently  various  sclerosed  areas,  which  indicate 
the  occurrence  of  encephalitides,  are  found  in  the  brains  of 
epileptics.  These  are  frequently  met  with  in  the  hippocampus, 
and  considerable  importance  has  been  attached  by  certain  au- 
thorities to  this  finding.  Recently  attention  has  been  called  to 
the  fact  that  this  change  is  in  reality  a  hypoplasia  referable  to 
defects  in  the  development  of  the  brain.  In  some  cases  also 
there  is  a  marked  gliosis  of  the  hippocampus  with  disappear- 
ance of  ganglion  cells  from  certain  portions  of  the  lobe. 

Chronic  meningitis  plays  an  important  role  in  cases  of 
idiocy  associated  with  epilepsy.  Nor  should  it  be  forgotten 
that  even  when  local  cerebral  lesions  are  known  to  exist  in  cases 
of  epilepsy  in  the  majority  of  cases  it  is  impossible  to  establish 
a  direct  connection  between  their  existence  and  the  occurrence 
of  the  attacks.  The  same  is  true  in  regard  to  the  rtyperaemias 
and  stases  in  the  cerebral  vessels,  inasmuch  as  these  are  of  sec- 
ondary and  not  primary  importance.19  For  a  long  time  the 
changes  in  the  blood-vessels  in  the  brain  of  epileptics  have  re- 
ceived careful  attention  from  investigators,  and  a  dilatation  of 
the  fine  cortical  arterioles,  veins,  and  capillaries,  as  well  as  the 
formation  of  new  ones,  have  been  reported.  In  most  of  the 
cases  the  vascular  changes  are  plainly  the  result  and  not  the 
cause  of  epilepsy. 

Hydrocephalus,  either  congenital  or  acquired,  is  not  infre- 
quently noted,  and  in  cases  of  epilepsy  which  have  extended 
over  a  considerable  period  of  time  there  is  a  marked  increase  of 


39  Jolly,  F. :  Pathologische  Anatomie  der  Epilepsie  und  Eklampsie. 
Handbuch  der  pathol.  Anatomie  der  Nervensystems.  Abt.  iv.  (Bog.  61- 
81),  Berlin,  1903,  S.  1276. 


THE   EPILEPSY    GROUP 


493 


the  subpial  felting,  as  well  as  in  the  number  of  the  superficial 
cortical  vessels.  Weber  20  has  shown  that  in  other  cases  there  is 
a  localized  irregular  increase  of  the  perivascular  glia  fibres, 
both  coarse  and  fine,  that  in  some  places  fills  up  the  whole  of  the 
outer  layer  of  the  cortex  and  completely  obliterates  the  vessels. 
There  is  also  an  increase  in  the  number  of  glia  nuclei,  and  the 
presence  of  large  spider-cells  with  coarse  processes  is  noted  in 
cases  where  there  is  a  localized  encephalitic  inflammation.  The 
increase  in  the  glia  is  in  all  probability  secondary  rather  than 
primary  in  character.  Often  there  is  a  heaping  up  of  small 
round  cells,  probably  neuroglia  elements,  about  the  larger 
nerve-cells,  and  the  latter  when  closely  examined  may  show  an 
excentric  position  of  the  nucleus  and  considerable  degeneration 
of  the  granules.  These  changes,  however,  are  not  in  any  sense 
specific. 

20  Weber,  L.  W. :    Beitrage  zur  Pathogenese  und  patholog.  Anatomie 
der  Epilepsie.    Jena,  1901. 


CHAPTER   XVII 

THE    HYSTERIA    GROUP  1 

Although  a  perfectly  satisfactory  definition  of  this  dis- 
order cannot  be  given,  its  chief  manifestations  are  easily  recog- 
nizable and  are  capable  of  analysis  and  description.  According 
to  our  present  views,  hysteria  is  now  held  to  be  a  disease  which, 
to  a  greater  or  lesser  extent,  affects  the  entire  organism,2  and 
the  mental  anomalies  associated  with  it  are  sufficiently  marked 
to  justify  its  inclusion  among  the  psychoses.  Sydenham  was 
the  first  to  describe  hysteria  as  a  disease  of  the  nervous  sys- 
tem, but  it  remained  for  Charcot  to  affirm  that  hysteria  was 
a  psychic  malady  par  excellence  and  for  Janet3  to  see  in  this 
disorder  "  a  form  of  mental  disintegration  characterized  by 
a  tendency  towards  the  permanent  and  complete  dissociation 
of  the  personality.  The  symptoms  are  both  primary  and  sec- 
ondary. The  former  are  capable  of  being  reproduced  by  sug- 
gestion ;   the  latter  are  more  subordinate  in  character. 

The  psychic  abnormalities  of  hysterical  individuals  may 
be  roughly  divided  into  the  following  categories :  4  ( I )  The 
ideas  or  representations  of  the  patient's  own  body,  the  so-called 
organic  sensations,  appear  in  consciousness  with  an  abnormal 
degree  of  intensity.  (2)  The  emotional  reactions  directly  and 
indirectly  connected  with  this  complex  of  sensations  may  be 
so  intensified  as  to  interfere  with  both  sensory  and  motor  func- 
tions. 

For  a  full  description  of  the  physical  symptoms  of  hysteria 

1  Preston,  George  J. :  Hysteria  and  Certain  Allied  Conditions,  1897. 
Binswanger :  Die  Hysteric  A.  Holder.  Wien,  1904.  Hellpach,  W. :  An- 
alytische  Untersuchungen  zur  Psychologie  der  Hysteric  Centralbl.  f. 
Nervenheilk.  u.  Psych.,  Bd.  xv,  1903,  p.  736. 

'Briquet:    Traite  de  l'hysterie,  1859,  p.  517. 

8 Janet:  The  Mental  State  of  Hystericals.  Translated  by  Corson.  G. 
P.  Putnam's  Sons,  1901. 

*  Weygandt :    Psychiatrie,  Muenchen,  1902. 

494 


HYSTERIA 


495 


the  reader  is  referred  to  the  various  text-books  of  neurology 
as  well  as  to  the  monographs  on  this  subject.  The  more  com- 
plex mental  phenomena  of  this  disease  are  largely  conditioned 
by  (i)  disturbances  of  the  attention;  (2)  anomalies  of  emo- 
tion; and  finally,  (3)  a  general  interference  with  the  normal 
mental  functions,  particularly  noticeable  in  the  disturbances  of 
memory  and  in  the  vivid  play  of  the  imagination.  As  these 
primary  symptoms  may  give  rise  to  a  variety  of  disturbances 
of  the  mental  processes  the  latter  may  be  advantageously 
studied  from  many  different  stand-points.  Briefly  stated,  then, 
the  mental  stigmata  consist  in  anaesthesias,  amnesias,  and  abu- 
lias. The  normal  sense  perception  is  not  infrequently  inter- 
fered with  and  patients  frequently  suffer  from  anaesthesias, 
paresthesias,  hyperesthesias,  and  disorders  of  sensation,  so 
distributed  as  not  to  correspond  with  the  peripheral  distribution 
of  any  one  nerve,  and  which  for  this  reason  are  more  properly 
described  as  psychic  anaesthesias,  psychic  paraesthesias,  and 
psychic  hyperaesthesias. 

The  anaesthesias  or  hyperaesthesias  are  sometimes  limited 
to  one-half  of  the  body — hemianaesthesias,  hemihyperaesthesias 
— or  occur  in  areas  forming  plaques  or  geometrical  figures.5 
As  has  been  said  above,  the  disturbances  in  sensation  bear  no 
relation  to  the  distribution  of  the  peripheral  nerves  and  may 
be  general,  localized,  or  selective  in  character.  For  example, 
there  may  be  insensibility  to  pain  and  heat  or  only  to  the  un- 
comfortable sensations  produced  by  forcible  movements  of  the 
limbs.  Another  important  characteristic  of  these  disturbances 
is  their  tendency  to  become  systematized.  Thus,  some  patients 
affirm  that  they  are  able  to  see  certain  objects  or  certain  per- 
sons and  not  others.  The  selection  in  these  cases  seems  to  be 
determined  by  the  mental  state  of  the  individual.  General 
anaesthesias  are  occasionally  noted.  The  hyperaesthesias  or 
hyperalgesias  are  associated  with  various  organs  and  take  the 
form  of  myalgias,  cephalalgias,  pleuralgias,  etc.  In  all  proba- 
bility, however,  they  are  much  rarer  occurrences  than  is  com- 

5  Charcot :    Legons  sur  les  maladies  du  systeme  nerveux. 


496  PSYCHIATRY 

monly  supposed.  In  regard  to  these  phenomena  one  must  be 
careful  to  distinguish  between  the  cases  in  which  there  is  an 
apparent  and  a  real  accentuation  in  the  sense  acuity.  Moreover, 
there  exist  certain  phenomena,  commonly  referred  to  as  hyper- 
esthesias, that  are  of  purely  psychic  origin  and  are  referable 
to  the  presence  of  certain  fixed  ideas.  In  such  cases  the  patient 
is  not  only  extremely  sensitive  to  all  forms  of  external  stimu- 
lation, touch,  heat,  cold,  etc.,  but  is  also  affected  by  a  general 
mental  hyperesthesia  frequently  shown  by  the  fact  that  he 
complains  of  suffering  acutely  before  any  cause  has  been  oper- 
ative ;  and  again,  these  psychic  hyperesthesias  or  hyperalgesias 
are  often  combined  with  actual  anesthesias.  Thus,  one  of 
Janet's  patients  would  shriek  with  pain  as  soon  as  the  exam- 
iner's hand  approached  her  abdomen,  but  immediately  her 
attention  was  distracted,  it  was  observed  that  there  was  an 
actual  diminution  of  sensation.  The  fixed  ideas  not  only  have 
a  remarkable  effect  upon  general  cutaneous  sensibility,  but  also 
upon  the  special  organs,  such  as  vision  and  hearing. 

The  contradictory  characteristics  of  the  sensory  anomalies 
are  more  particularly  of  diagnostic  importance.  They  often 
change  with  great  rapidity  and  are  largely  influenced  by  sug- 
gestion. Not  infrequently  the  sense  organs  seem  to  be  in  a 
state  of  hyperexcitation,  so  that  in  the  visual  sphere  we  may 
meet  with  hallucinations  and  illusions.  The  former  are  more 
apt  to  be  elementary,  although  at  times  patients  affirm  that  they 
see  visions  of  the  character  to  be  described  later.  Elementary 
auditory  hallucinations  occur,  but  are  less  common.  Some- 
times these  phenomena  seem  to  be  purely  subjective  and  appear 
even  in  the  absence  of  any  well-defined  external  stimulus,  while 
at  other  times  they  are  evidently  illusions. 

As  a  rule,  these  disturbances  are  associated  with  marked 
emotional  anomalies  and  are  accompanied  in  many  cases  by 
attacks  of  pain — headache,  intercostal  neuralgias,  etc.  Their 
duration  varies  from  a  few  minutes  to  several  hours,  seldom 
longer.  Their  subjective  character  is  usually  recognized  by 
the  patients,  who  appreciate  the  fact  that  they  are  abnormal, 
and  their  conduct,  with  the  exceptions  referred  to  later,  is  sel- 


HYSTERIA 


497 


dom  actuated  or  dominated  by  these  fallacious  sense  percep- 
tions. Micropsia  and  macropsia  are  not  infrequently  noted, 
and  in  many  instances  it  is  possible  to  produce  hallucinations 
by  mere  suggestion.  The  taste  and  smell  are  affected  in  a 
large  percentage  of  the  cases.  Hysterical  patients  generally 
show  idiosyncrasies  in  their  sensory  predilections,  expressing 
preference  for  unusual  dishes,  taking  pleasure  in  such  odors 
as  that  of  asafoetida  or  valerian — odors  that  are  wont  to  be 
particularly  objectionable  to  the  normal  individual.  The  atten- 
tion of  these  patients  is  readily  gained,  but  quickly  lapses,  and 
can  only  be  sustained  with  great  effort.  These  fluctuations  un- 
questionably form  the  basis  of  many  of  the  amnesic  defects  to 
which  reference  will  presently  be  made.  This  condition — the 
so-called  aprosexia — was  first  described  by  Guge  in  referring 
to  the  lapse  of  attention  noticeable  in  patients  suffering  from 
some  obstruction  in  the  nasal  passages.  The  symptom  can 
often  be  readily  demonstrated.  If  the  patients  are  made  to 
read  either  to  themselves  or  out  aloud,  although  the  words  may 
be  pronounced  correctly  and  without  delay,  it  is  quite  evident 
that  the  sense  of  the  sentence  is  not  apprehended.  Whole 
paragraphs  may  be  read  without  the  individual  being  able  to 
recollect  any  of  the  words.  If  the  patient  is  forced  to  stimulate 
the  attention  to  the  utmost,  there  is  often  to  be  noted  a  reflex 
series  of  phenomena,  such  as  headache,  vertigo,  various  indefi- 
nite pains,  and  more  or  less  nervousness  which  may  lead  to 
emotional  outbreaks.  On  account  of  the  marked  distractibility 
hysterical  patients  are  frequently  led  to  errors  in  interpretation 
of  a  great  variety  of  phenomena  and  events,  and  this  fact  is 
fundamentally  responsible  for  many  of  the  apparent  inconsis- 
tencies and  contradictions  in  their  character  that  are  commented 
upon  by  the  laity.  The  defects  in  memory  are  characterized 
by  a  considerable  degree  of  capriciousness,  and  not  uncom- 
monly may  be  increased  or  diminished  by  suggestion. 

The  systematization,  frequently  characteristic  of  the  sen- 
sory disturbances,  is  also  noticeable  in  regard  to  the  amnesias. 
Many  hysterical  patients  forget  only  certain  facts  connected 
with  the  train  of  thought,  while  retaining  a  logical  and  uninter- 

32 


498  PSYCHIATRY 

rupted  recollection  of  others.  Such  forms  of  amnesia  occur 
not  only  for  events,  but  in  regard  to  persons  and  particularly 
for  language.  This  last  defect  may  be  so  pronounced  as  to 
give  rise  to  difficulties  in  differentiating  the  case  from  one  of 
aphasia.  The  loss  of  memory  may  be  restricted  not  only  in 
this  way,  but  may  also  include  the  muscular  movements,  being 
sometimes  limited  to  those  concerned  with  articulation  or  with 
the  performance  of  certain  definite  acts ;  or  in  severer  types  it 
may  be  much  more  extensive  and  involve  the  muscles  of  the 
limbs  and  trunk,  as  in  astasia  abasia. 

Among  the  more  complicated  forms  of  hysterical  amnesia 
are  disturbances  in  the  sense  of  recognition,  an  anomaly  which 
has  recently  been  described  by  a  number  of  observers.6  Pa- 
tients who  are  afflicted  in  this  way  not  infrequently  affirm  that 
there  has  come  about  a  marked  change  in  their  sensations,  so 
that  they  are  unable  to  recognize  their  surroundings  and  famil- 
iar objects.  The  feeling  is  common  in  hysteria,  but  may  also 
occur  in  epilepsy  as  well  as  in  other  neuroses.  Thus  a  patient 
will  often  affirm  that  he  is  more  or  less  suddenly  "  overwhelmed 
by  an  indescribable  sensation  that  makes  everything  seem 
strange  and  far  away." 

As  has  frequently  been  pointed  out,  the  disturbances  of 
volition  are  characterized  by  a  series  of  changes  similar  to  those 
noted  in  connection  with  sensation  and  memory.  The  abulias 
may  be  both  local  and  general  as  well  as  characterized  by  more 
or  less  systematization.  The  intellectual  forms  seem  to  be  in 
a  measure  dependent  upon  the  patient's  inability  to  think  cor-_ 
rectly,  but  when  a  synthesis  has  once  been  established — for  ex- 
ample, when  a  new  idea  has  given  direction  to  a  train  of 
thought — this  not  infrequently  persists. 

What  has  been  said  in  regard  to  the  mental  abulias  is 
equally  true  of  those  with  which  emotional  reactions  are  ordi- 
narily associated.  A  hysterical  patient  will  always  hesitate 
about  beginning  a  new  series  of  movements,  and  when  told  to 

"Pick:  Neurol.  Centralbl.,  Jan.  i,  1903.  Alter,  W. :  Ueber  eine 
seltenere  Form  geistiger  Stoning.  Monatsschr.  f.  Psych,  u.  Neurol.,  1903, 
Bd.  xiv,  H.  4,  S.  246. 


HYSTERIA  499 

do  a  certain  thing  he  may  make  the  attempt,  but  the  effort  is 
feeble,  spasmodic,  and  soon  fails.  Such  individuals  give  one 
the  impression  of  being  unable  to  gather  up  sufficient  force  at 
the  outset  to  overcome  an  initial  resistance,  and  for  this  reason 
an  act  when  once  committed  is  frequently  repeated  and  becomes 
in  time  partially  automatic. 

These  abulias  in  hysteria  exert  a  marked  reflex  effect  upon 
the  whole  mental  attitude  of  the  patient.  The  totality  of  the 
emotional  reactions  in  hysteria  is  reduced  as  compared  with 
those  occurring  in  the  healthy  normal  individual.  Only  a  com- 
paratively few  stimuli — the  insistent  ideas — serve  to  awaken 
an  emotional  response.  The  hysterical  individual  can  hardly 
be  regarded  as  a  person  with  broad  interests;  he  usually  be- 
comes cynical  and  narrow-minded  in  regard  to  everything  that 
does  not  immediately  pertain  to  himself.  On  the  surface  he 
may  be  apparently  generous  and  disinterested,  but  when  his 
character  is  closely  studied  it  will  seem  that  there  has  come 
about  a  great  narrowing  of  the  intellectual  horizon.  These 
anomalous  emotional  states  are  often  well  marked  and  explain 
both  the  general  attitude  of  the  hysterical  patient  to  his  imme- 
diate environment  as  well  as  his  general  loss  of  interest,  as  a 
consequence  of  which  he  is  usually  found  to  be  devoid  of  altru- 
ism and  markedly  deficient  in  many  social  instincts,  so  that  he 
frequently  expresses  a  longing  to  be  left  alone  and  seems  de- 
sirous of  becoming  more  or  less  isolated.  Nevertheless,  on 
account  of  his  impressionability,  a  paradoxical  state  develops 
in  which  noble  sentiments,  such  as  those  of  gratitude  or  sym- 
pathy, are  passionately  expressed,  but  as  promptly  forgotten. 

The  hysterical  modifications  in  character,  to  which  allusion 
has  already  been  made,  are  very  varied  and  incongruous,  and 
the  disturbances  in  sensation,  attention,  and  memory  in  turn 
give  rise  to  a  dissociation  of  the  personality.  No  single  feature 
of  these  anomalies  of  character  is  as  constant  as  their  incon- 
stancy (Sydenham).  Hysterical  individuals  are  incapable  of 
any  prolonged  effort,  for  the  reason  that  they  lack  the  power 
of  concentration  and  because  the  focus  of  their  attention  is 
constantly  changing.     It  is  true  that  individuals  belonging  to 


500  PSYCHIATRY 

the  highly  intellectual  class  may  be  easily  interested  and  are  at 
times  vivacious  and  animated,  but  the  intelligence,  far  from 
being  progressive,  is  frequently  retrograde.  The  knowledge 
accumulated  by  these  persons  is,  as  a  rule,  superficial,  although 
it  may  cover  a  great  variety  of  subjects.  The  countless  lapses 
in  attention  and  the  accompanying  amnesia  often  render  it  im- 
possible for  such  individuals  to  add  materially  to  their  store 
of  knowledge,  inasmuch  as  each  new  stimulus  from  without 
seems  to  divert  and  disorganize  the  train  of  thought.  When 
their  attention  is  obtained,  the  observer  is  particularly  struck 
not  only  by  the  ease  with  which  it  lapses,  but  by  the  fact  that 
it  can  be  only  partially  diverted  to  subjects  that  lie  outside  the 
patient's  own  individuality.  If  the  patient  is  aroused  from  an 
apparent  revery,  momentary  attention  is  given  to  what  is  being 
said,  but  not  infrequently  the  conversation  is  broken  by  the 
interjection  by  the  patient  of  some  quite  irrelevant  idea  that  has 
evidently  just  at  that  instant  crossed  the  field  of  attention. 

In  addition  to  the  changes  already  noted,  hysterical  pa- 
tients are  apt  to  be  exceedingly  selfish,  this  trait  manifesting 
itself  in  a  great  many  different  ways  and  being  the  direct  result 
of  the  dissociation  which  occurs  in  personality.  Such  individ- 
uals seem  so  absorbed  in  their  own  tiny  world  that  they  fail 
to  grasp  in  any  sense  their  relationship  to  their  immediate  fam- 
ily and  friends.  This  symptom  is  the  result  of  the  general 
mental  impairment  as  well  as  of  the  diminution  in  the  number 
of  the  emotional  reactions.  Hence  it  is  not  surprising  that 
hysterical  individuals  show  remarkable  inconsistencies  in  char- 
acter, and  these  in  their  turn  are  dependent  upon  the  physical 
defects  in  function  to  which  reference  has  already  been  made. 
Prominent  among  the  mental  idiosyncrasies  of  these  patients 
is  a  tendency  to  lie.  This  failing  is  often  referable  to  the  same 
cause  as  that  which  engenders  untruthfulness  in  children — 
namely,  fear.  In  many  instances  hysterical  individuals  have 
a  strong  tendency  to  deceive  on  account  of  a  desire  to  conceal 
their  defects  combined  with  a  craving  for  sympathy  from 
others.  The  abnormal  activity  of  the  imagination  in  hysterical 
patients  is  another  fertile  source  of  their  lack  of  veracity.    Not 


HYSTERIA  501 

infrequently  these  individuals  tell  about  the  most  extraordinary 
adventures  that  they  affirm  have  happened  to  them,  but  which, 
upon  investigation,  are  shown  not  to  be  based  upon  a  single 
fact.  These  Munchausen-like  narratives  not  infrequently  refer 
to  extraordinary  scenes  through  which  the  individual  has 
passed  or  to  events  that  have  occurred  in  his  daily  life.  The 
history  of  the  following  case  affords  an  excellent  illustration 
of  this  type  of  hysterical  liar : 

Male,  aged  24,  admitted  to  the  Sheppard  and  Enoch  Pratt  Hospital. 

Family  History. — Maternal  uncle  insane.  No  other  history  of  ner- 
vous or  mental  disease. 

Personal  History. — Born  at  full  term.  Paralyzed  at  the  age  of  3 
on  the  right  side,  and  did  not  recover  for  several  months.  Otherwise 
growth  and  development  were  normal.  He  walked  and  talked  at  the 
usual  age.  Began  school  at  6.  He  was  more  or  less  nervous  as  a  child, 
but  submitted  fairly  well  to  disappointments  and  gave  up  without  giving 
expression  to  his  own  desires.  He  did  not  care  for  study,  but  showed 
a  great  desire  to  travel  and  read  books  on  such  subjects.  His  memory 
was  good.  There  is  no  history  of  definite  disease.  In  character  he  has 
been  excitable,  rambling,  vacillating,  impulsive.  He  has  been  a  regular 
and  sound  sleeper  until  a  short  time  ago.  He  affirms  that  he  has  never 
taken  a  drink  in  his  life,  and  has  never  used  tobacco.  For  some  time  he 
has  had  nervous  spells,  during  which  he  has  taken  occasional  doses  of 
morphin,  prescribed  by  a  physician. 

The  present  illness  is  attributed  to  overwork,  ill-health,  and  disappoint- 
ment. Eighteen  months  ago  he  insisted  on  going  upon  the  stage  against 
the  wishes  of  his  family,  though  they  finally  consented.  He  began  to  study 
in  a  dramatic  school,  but  was  not  successful.  He  then  travelled  about  with 
a  company.  Three  weeks  prior  to  his  admission  the  patient  had  written 
to  his  father,  asking  for  a  sum  of  money  as  a  ransom,  which  was  to  be 
paid  to  persons  living  in  the  boarding-house  where  he  was  staying.  This 
boarding-house,  of  questionable  character,  was  in  a  town  over  one  hun- 
dred miles  distant  from  the  city  in  which  the  patient  had  lived.  On  being 
questioned  the  patient  affirmed  that  he  had  walked  to  this  town  from  the 
city  in  company  with  a  young  man ;  but  he  either  could  net  or  would  not 
give  any  further  explanation.  His  condition  at  this  time  was  described  as 
weak,  and  the  patient  seemed  apathetic,  although  at  times  he  complained 
a  good  deal  of  pain  about  his  heart.  When  admitted  to  the  hospital  he 
had  attacks  of  apparent  unconsciousness.  At  times  he  was  violent,  and 
had  to  be  restrained,  although  he  had  offered  no  objection  to  being  brought 
to  the  hospital  and  seemed  perfectly  rational.  He  spent  a  good  deal  of 
his  time  in  reading  or  walking,  and  enjoyed  bowling  and  playing  games. 

Physical  Examination. — Well  developed,  not  very  muscular.  Tongue 
protruded  in  middle  line,  straight,  not  tremulous. 

Eyes:     Pupils  well  dilated,  react  fairly  to  accommodation. 


502  PSYCHIATRY 

Heart :  No  enlargement ;  sounds  normal.  Dermatographia  very  rapid 
and  diffuse.  (During  the  examination  the  patient  said  that  he  had  had  a 
number  of  nervous  attacks  during  the  past  few  months.  He  could  tell 
when  the  attacks  were  coming  on.  He  said  that  a  pain  started  in  his 
heart  and  extended  down  to  his  hip ;  later  he  could  feel  this  from  his  head 
to  the  tips  of  his  toes.  The  sensation  he  experienced  was  as  if  a  knife 
were  sticking  into  his  heart  and  there  was  red-hot  blood  in  his  veins. 
When  overwhelmed  by  these  attacks  he  was  very  nervous  and  could  not 
sit  still.) 

His  attention  is  easily  obtained  and  well  maintained.  He  gives  a 
disconnected  account  of  his  experiences,  and  does  not  seem  to  understand 
that  his  story  must  fail  to  impress  others  as  being  truthful.  He  gives 
utterance  to  a  great  many  inconsistencies,  some  of  which  he  recognizes. 
His  own  account  of  his  conduct  prior  to  his  appearance  in  the  boarding- 
house  referred  to  is  as  follows :  He  was  in  the  company  for  two-and-a- 
half  years  and  was  getting  on  very  well,  although  others  may  not  have 
thought  so.  He  proposed  to  a  friend  that  they  form  a  company  of  their 
own.  This  they  were  unable  to  do  through  lack  of  funds.  Following  this, 
he  was  engaged  to  play  in  a  stock  company.  While  on  his  way  to  join 
it  with  a  friend  he  was  waylaid  in  an  unfrequented  street  by  two  men, 
who  chloroformed  him.  He  did  not  entirely  lose  consciousness,  and  felt 
a  revolver  in  the  pocket  of  one  of  his  captors,  and  thus  realized  that  re- 
sistance was  useless.  He  and  his  friend  were  confined  in  a  room  in  the 
city  until  finally  they  made  their  escape.  During  the  time  that  he  was  tied 
he  lost  from  a  pint  to  a  quart  of  blood. 

The  story  is  altogether  improbable,  and,  as  the  patient  narrates  it, 
full  of  inconsistencies. 

While  in  the  hospital  he  has  had  nervous  attacks,  preceded  by  pain  in 
the  region  of  the  heart,  with  some  motor  restlessness,  during  which  he 
walks  up  and  down  the  room  wringing  his  hands  and  crying  aloud.  The 
attacks  can  be  quieted  by  a  hypodermic  injection  of  distilled  water. 

Another  factor  of  importance  in  the  hysterical  stigmata  is 
supplied  by  the  over-valuation  and  persistence  of  certain  ideas. 
Reference  has  already  been  made  to  this  point,  and  it  has  long 
been  known  that  this  phenomenon  is  important  not  only  in  the 
production  of  the  disturbances  in  sensation  and  motility,  but 
also  dominates  all  the  mental  processes  of  the  hysterical  per- 
son. It  frequently  happens  that  this  remarkable  play  of  the 
imagination  is  associated  with  an  abnormal  emotional  state, 
during  which  the  subsequent  acts  of  the  individual  seem  to 
be  guided  purely  by  an  intense  egotism  or  by  impulses  which 
are  the  result  of  a  passionate  outbreak.  As  a  rule,  such  indi- 
viduals show  a  remarkable  deftness  and  great  ingenuity  in 


HYSTERIA 


503 


concealing  all  the  consequences  of  the  unlawful  acts  which  they 
may  have  committed.  Examples  of  this  are  occasionally  met 
with  in  the  law  courts,  where  an  attempt  at  poisoning  or 
murder  has  been  completely  covered  up  by  the  patient. 

The  suggestibility  of  hysterical  patients  is  very  great,  and, 
as  has  already  been  said,  anaesthesias,  amnesias,  paralyses,  and 
abulias  may  be  induced  by  this  agency  in  the  form  of  a  single 
idea  or  a  complex  train  of  thought  that  occupies  the  entire  field 
of  consciousness.  Sometimes  single  sensations  may  be  inter- 
posed to  form  a  link  in  the  chain  of  thought ;  for  example,  an 
attack  of  pain  in  any  part  of  the  body  may  be  associated  with 
the  idea  of  injury.  The  train  of  thought  may  be  so  compli- 
cated as  to  completely  occupy  the  field  of  attention,  and  while 
this  lasts  may  completely  transform  the  individual.  In  some 
instances  a  condition  occurs  which  has  been  described  as  delife 
ecmnesique.7  In  this  state  individuals  are  completely  preoccu- 
pied by  events  which  have  happened  at  a  period  long  antedating 
the  attack,  and  both  by  their  conduct  as  well  as  by  their  whole 
mental  state  reveal  the  fact  that  they  live  in  the  past.  It  is 
important  to  note  that  under  the  influence  of  suggestion,  if  any 
train  of  thought  is  once  diverted  by  an  external  stimulus,  this 
serves  as  a  starting-point  about  which  new  ideas  cluster.  This 
frequently  means  that  a  complete  series  of  visual  and  auditory 
as  well  as  kinesthetic  representations  are  re-collected  and  re- 
developed, this  growth  in  mental  elaboration  being  more  or 
less  automatic  and  depending  upon  a  repetition  of  ideas  and 
memory  pictures  which  have  once  been  stamped  upon  con- 
sciousness. During  this  process  the  sensations  upon  which  the 
idea  of  individuality  depends  are  reduced  to  a  minimum;  per- 
ception becomes  altered  in  character,  and,  as  a  rule,  the  repre- 
sentations are  but  faintly  stamped  upon  the  memory,  a  fact 
which,  more  than  any  other,  serves  to  differentiate  the  thoughts 
and  acts  of  hysterical  patients  from  those  of  normal  indi- 
viduals. 

The  dream  states  which  occur  during  the  course  of  hysteri- 

7  Pitres :   Lemons  cliniques  sur  l'hysterie,  ii,  p.  293. 


504 


PSYCHIATRY 


cal  attacks  are  not  at  all  uncommon  and  present  many  qualities 
that  are  striking  and,  in  a  measure,  characteristic.  According 
to  Sollier,8  hysterical  patients  are  always  in  a  pathological  state 
of  dreaminess,  and  this  drowsiness  and  the  anaesthesias  are 
practically  one  and  the  same,  so  that  it  suffices  to  completely 
arouse  the  hysterical  person  in  order  to  entirely  restore  sensa- 
tion. Such  individuals,  if  left  undisturbed,  easily  lapse  into  a 
state  of  revery,  so  that  it  may  easily  be  said  of  them  that  "  they 
are  not  content  to  dream  constantly  at  night;  they  dream  all 
day  long." 

In  these  conditions  the  patient,  while  under  observation, 
seems  to  be  wool-gathering,  is  confused,  falls  into  a  state  of 
dream-like  revery.  Speech  may  be  limited  to  monosyllables, 
is  sometimes  incoherent,  and,  although  the  patient  may  seem 
to  be  emotional  and  apparently  desirous  of  describing  his  sen- 
sations, he  is  unable  to  do  so.  Not  infrequently  the  speech  is 
characterized  by  marked  irrelevancy  (Vorbeireden).9  During 
these  states  there  is  a  very  marked  narrowing  of  the  field  of 
consciousness  and  a  temporary  suspension  of  many  of  the  func- 
tions of  association.  The  acts  that  have  the  appearance  of 
volition  are,  in  a  measure,  influenced  by  the  idea  which  at  the 
time  happens  to  occupy  the  field  of  consciousness.  This  point 
is  well  illustrated  in  the  cases  that  are  influenced  by  hypnotiza- 
tion,  and  for  this  reason  have  been  described  as  hypnoid  states 
(Breuer).  During  these  dream  states  individuals  may  per- 
form curious  and  inexplicable  acts,  in  some  instances  commit- 
ting crimes,  such  as  theft  or  arson;  or  at  other  times  their 
conduct  seems  to  be  purposeless  and  without  any  apparent  ap- 
preciation of  its  real  significance.10     Sometimes  these  dream 

8  Genese  et  nature  de  l'hysterie.     Paris,  Alcan,  1897. 

9  Ganser :  Ueber  einen  eigenartigen  hysterischen  Dammerzustand. 
Arch.  f.  Psych,  u.  Nervenkrankh.,  xxx,  S.  633.  Zur  Lehre  von  hysteri- 
schen Dammerzustande.  Arch.  f.  Psych,  u.  Nervenkrankh.  xxxviii,  Hft.  1, 
1904.  Nissl :  Hysterische  Symptome  bei  einfachen  Seelenstorungen.  Cen- 
tralbl.  f.  Nervenheilk.  u.  Psych.,  xxv.  Jahrg.,  Jan.,  1902.  Westphal,  A. : 
Ueber  hysterische  Dammerzustande  und  das  Symptom  des  Vorbeiredens. 
Neurolog.  Centralbl.,  Jan.  1  and  16,  1903. 

10  Wollenberg :    Handbuch  der  gerichtlichen  Psychiatric     Berlin,  1901. 


HYSTERIA  505 

states  are  interrupted  by  impulsive  acts  which,  in  a  measure, 
resemble  those  committed  by  patients  in  the  early  stages  of 
dementia  praecox. 

The  following  abstract  serves  to  indicate  many  of  the  hys- 
terical traits: 

Female,  aged  25.     Single. 

Family  History. — Father  nervous.  Two  brothers  of  the  patient  are 
also  nervous.  Otherwise  the  family  history  is  negative  for  any  nervous  or 
mental  disease. 

Personal  History. — No  serious  illness  except  scarlatina  and  diphtheria. 
Her  health  in  childhood  was  good.  She  received  a  severe  fright  when  5 
years  old.  The  patient  affirms  that  she  can  never  remember  the  time 
when  her  mind  was  not  morbid.  The  catamenia  began  at  14,  and 
were  preceded  by  attacks  of  great  nervousness.  The  lack  of  sympathy 
between  herself  and  her  mother  and  her  own  hypersensitiveness  gave  rise 
(she  affirms)  to  untruthfulness.  Even  as  a  child  she  expressed  a  desire 
to  become  a  trained  nurse.  Apparently  the  periods  of  depression  ante- 
dated puberty  by  a  long  time,  and  she  affirms  that  the  idea  of  suicide  has 
been  in  her  mind  for  a  great  part  of  her  life.  After  her  fourth  menses 
the  patient  disappeared  from  home  and  was  absent  long  enough  to  oc- 
casion some  anxiety.  She  returned  later  in  the  day,  and  from  the  account 
given  had  apparently  been  wandering  about  aimlessly.  As  a  rule,  she  is 
very  nervous  and  fussy  during  the  menstrual  period.  Her  first  marked 
nervous  breakdown  occurred  when  she  was  about  16  years  of  age.  She 
began  to  study  nursing  at  18,  but  was  unable  to  stand  the  strain.  She 
suffered  from  some  flow  recurring  every  week  or  two,  and  was  operated 
upon  for  retroflexion.  She  says  that  she  went  a  good  deal  into 
society,  and  being  very  nervous  she  felt  the  need  of  stimulants,  so  that  she 
took  small  amounts  of  whiskey.  She  did  not  form  the  whiskey  habit,  but 
began  the  use  of  coffee  instead.  Later,  she  drank  a  great  deal  of  tea.  In 
1900  she  complained  of  constant  fatigue.  Being  threatened  with  the  rest- 
cure  she  relinquished  the  idea  of  spending  most  of  the  time  in  bed. 
She  had  a  number  of  hysterical  attacks.  She  often  assumed  a  theatrical 
manner  and  affected  not  to  know  her  friends.  She  was  found  one  day 
by  her  mother  inhaling  chloroform.  Once  when  visiting  a  friend  she  left 
the  house,  saying  she  was  bored  and  that  she  would  return  when  she  got 
ready.  Between  five  o'clock  one  afternoon  and  the  next  morning  at  eight 
she  wandered  about  in  the  woods.  The  recollection  of  this  event  seems 
to  be  somewhat  defective.  Soon  after  this  she  declared  that  she  intended  to 
get  some  poison  and  go  to  a  deserted  house,  after  having  gotten  rid  of  all 
her  jewelry  and  clothing  which  could  identify  her,  melting  the  jewelry  and 
burning  the  clothing,  and  then  swallowing  the  poison.  Of  that  night  she 
only  remembers  "the  woods  and  the  wind."  She  has  been  very  emotional 
and  talkative  at  times,  and  at  others  depressed  and  much  given  to  talking 
about  suicide.    She  has  had  several  attacks  in  which  she  flings  herself  about 


506 


PSYCHIATRY 


the  bed,  but  soon  becomes  quiet  and  lucid.  She  is  very  self-centred,  feels 
compelled  to  constant  activity,  but  at  the  same  time  overcome  by  a  sense  of 
fatigue.  She  has  made  several  dramatic  attempts  at  suicide,  once  trying  to 
tie  a  shoe-string  tightly  about  her  neck.  She  occasionally  discusses  her 
mental  state,  and  at  times  affirms  that  she  expects  to  become  a  raving 
maniac. 

The  physical  examination  was  practically  negative.  Vision  good. 
Visual  field  unimpaired.  Pupils  moderately  dilated  and  very  active  to 
both  consensual  and  direct  light  reflexes. 

Urine,  slightly  acid,  specific  gravity  1029.  Very  faint  trace  of  albumin. 
Dense  cloud  of  phosphates  thrown  down  on  heating.  No  sugar.  The 
bodily  weight  is  said  to  vary  from  97  to  107  pounds. 

The  patient  was  discharged  somewhat  improved  after  being  two 
months  in  the  hospital.  She  went  to  a  private  sanitarium,  from  which 
she  escaped,  and  went  to  live  in  a  large  city,  as  she  thought  it  would  be 
necessary  for  her  to  become  a  working  girl.  She  was  there  for  nearly  two 
years  before  her  whereabouts  became  known  to  her  family,  and  was  finally 
found  only  by  the  merest  accident. 

The  duration  of  the  dream  periods  may  last  from  several 
minutes  to  weeks  or  even  months.  They  are  said  to  bear  some 
relation  to  the  hysterical  convulsions  preceding  or  following 
them,  or  to  form  the  so-called  psychic  equivalents.  During  this 
period  of  limitation  in  the  field  of  consciousness,  ideas  and  im- 
pulses that  have  been  prominent  during  the  lucid  intervals 
dominate  the  individual.  The  diagnosis  of  the  hysterical  dream 
state,  as  a  rule,  depends  upon  the  sudden  appearance  of  the 
disturbance,  which  is  generally  caused  by  some  immediate  and 
discoverable  motive;  or  it  may  be  the  final  stage  of  an  emo- 
tional outbreak. 

Hysterical  patients  are  frequently  given  to  somnambulism. 
This  phenomenon  presents  itself  under  a  great  variety  of  forms 
which  within  the  present  limits  cannot  be  described  in  detail, 
but  are  dealt  with  fully  in  the  works  of  Janet,  Gilles  de  la 
Tourette,  and  Hack  Tuke.  Many  writers  maintain  that  the 
somnambulism  of  children  is  one  of  the  earliest  symptoms  of 
hysteria,  as  is  shown  by  the  development  of  other  symptoms. 
The  somnambulist,  as  a  rule,  has  a  set  expression,  the  pupils 
are  more  or  less  immobile;  obstacles  placed  in  the  way  are 
generally  avoided,  and  the  patients  usually  do  not  injure  them- 
selves. 


HYSTERIA 


507 


In  addition  to  the  clinical  pictures  already  described,  quite 
a  number  of  delirious  states  may  occur  which  have  been  divided 
by  Colin  into  the  following-  categories :  n  ( 1 )  Delirious  mani- 
festations in  ordinary  hysteria;  (2)  an  hysterical  mental  state 
associated  with  definite  alienation.  Pitres  12  describes  three 
types  of  delirium:  (1)  hysterical  mania;  (2)  an  hallucinatory 
delirium;  (3)  delire  ecmnesique.  At  present  such  a  sharp  dif- 
ferentiation does  not  seem  to  be  practical.  The  delirium  is 
characterized  by  a  great  number  of  different  symptoms.  There 
may  be  marked  depression,  the  patient  being  hypochondriacal, 
self-centred,  and  giving  expression  to  countless  complaints; 
or,  on  the  other  hand,  there  may  be  excitement  with  a  feel- 
ing of  exaltation,  during  which  the  patient  may  perform 
numerous  silly  acts.  In  some  instances  during  the  delirium 
the  patient  raves  about  religious  subjects  or  becomes  profane 
and  obscene.  The  visual  and  auditory  hallucinations  pre- 
dominate and  in  many  cases  are  so  vivid  as  to  suggest  stages 
of  acute  alcoholism.  The  irritability  of  these  patients,  as  may 
be  inferred,  is  very  great,  but  is  not  characterized  by  the  offen- 
sive aggressiveness  seen  in  true  manic  states.  Their  emotional 
instability  is  one  of  the  most  characteristic  features,  the  phases 
in  the  delirium  changing  sometimes  with  almost  lightning-like 
rapidity.  During  these  states  the  patient  may  show  a  great 
tendency  to  an  exaggerated  play  of  phantasy,  depicting  situa- 
tions which  are  unreal,  so  that  it  is  frequently  difficult  to  find 
any  basis  for  their  bizarre  ideas.  In  some  cases  the  delirium 
is  colored  by  marked  sexual  irritation,  which  in  others,  how- 
ever, is  absent.  Occasionally  patients  are  apparently  over- 
whelmed by  periods  of  profound  anxiety,  which  seems  to  de- 
pend upon  the  existence  of  definite  phobias,  the  fear  of  losing 
the  mind,  of  committing  crimes,  of  death,  etc.,  which  may  be 
more  or  less  vague  in  their  genesis.  In  these  states  of  anxiety 
the  patients  not  infrequently  wander  about,  affirming  that  all 


11  Colin :    Etat  mentale  des  hysteriques.     Ballet's  Traite  de  pathologie 
mentale.     Paris,  1903. 

12  Pitres :    Legons  sur  l'hysterie  et  l'hypnotisme.     Paris,  1891. 


508  PSYCHIATRY 

hope  is  gone  from  them,  that  they  are  to  be  destroyed,  that  they 
are  past  all  help. 

According  to  Krafft-Ebing,  these  delirious  states  may  be 
divided  into  those  of  short  and  those  of  long  duration.  In  the 
former  condition  one  not  infrequently  meets  with  states  of 
marked  ecstatic  exaltation  alternating  with  periods  of  anxious- 
ness,  while  the  more  protracted  states  are  characterized  by  a 
greater  variety  of  hallucinations  and  a  moderate  dulling  of 
consciousness  with  considerable  systematization  in  the  various 
representations  that  appear  before  consciousness.  These  are 
the  cases  described  in  the  literature  under  the  head  of  hysterical 
hallucinatory  insanity.  The  attacks  may  begin  suddenly  and 
last  for  weeks  or  months  and  be  characterized  by  periods  of 
remission  or  intervals  when  there  is  a  relative  degree  of  lucid- 
ity. These  delirious  states  not  infrequently  develop  after  great 
mental  or  physical  fatigue  and  are  particularly  frequent  in 
women  after  severe  menorrhagias  as  well  as  during  the  puer- 
perium  and  climacterium.  The  systematization  is  sometimes 
marked;  ideasof  persecution,  of  having  committed  sins,  erotic 
desires  and  impulses,  as  well  as  religious  excesses,  are  promi- 
nent. Great  care  must  be  exercised  in  differentiating  these 
cases  from  those  of  manic-depressive  insanity.  Some  writers 
mention  a  more  protracted  form  of  the  malady  in  which  the 
various  disturbances  of  sensation  and  consciousness  are  more 
persistent  and  the  ideas  more  definitely  systematized.  These 
are  not  infrequently  described  as  hysterical  paranoioid  states, 
and  may  be  ushered  in  by  periods  of  depression  or  excitement 
characterized  by  marked  hysterical  symptoms.  Although  some 
of  them  are  unquestionably  instances  of  pure  hysteria,  the  fact 
should  never  be  lost  sight  of  that  others  mark  the  initial  stage 
of  various  psychoses. 

As  a  rule,  hysterical  mania  is  characterized  by  incessant 
movement  without  marked  incoordinated  agitation.  The  pa- 
tients throw  themselves  about,  roll  on  the  floor,  but  are  not 
apt  to  injure  themselves,  a  fact  that  is  partly  accounted  for 
by  the  presence  of  considerable  lucidity,  in  marked  contrast 
to  the  mental  state  in  mania.     The  conduct  is  capricious  and 


HYSTERIA  509 

menacing;  the  actions  are  frequently  eminently  contradic- 
tory.13 

Age. — Hysterical  symptoms  may  occur  in  children,  and 
descriptions  of  outbreaks  of  this  psychosis  in  young  persons  are 
not  infrequently  found  in  the  literature — the  chorea  major,  the 
dance  rage,  etc.  Since  Briquet's  work  in  1859  many  other 
excellent  clinical  pictures  of  the  disease  have  been  recorded,  and 
it  is  now  admitted  that  when  the  disorder  occurs  in  young 
people  in  at  least  one-fifth  of  the  patients  it  appears  before  the 
twelfth  year.  As  von  Strumpell  has  said,  "  If  hysteria  did  not 
exist  in  children,  there  would  be  no  '  wonder  cures'  and  no 
'  wonder  doctors.'  "  When  the  disease  makes  its  appearance 
before  puberty  it  comes  on,  as  a  rule,  between  the  seventh  and 
fourteenth  years.14 

Sex. — The  disorder  is  more  common  among  women  than 
among  men.  In  the  latter,  however,  the  symptoms  are  far  more 
apt  to  assume  a  serious  aspect  and,  as  a  rule,  are  characterized 
by  greater  tenacity  and  a  more  intense  depression.  After  the 
prime  of  life  has  passed  the  clinical  picture  in  both  sexes  corre- 
sponds more  to  the  male  type — hysterie  douloureuse  a  manifes- 
tation splanchnique.16 

Etiology. — The  etiology  of  the  disease  is  very  imper- 
fectly understood,  although,  generally  speaking,  the  majority 
of  the  cases  occur  in  individuals  with  a  psychopathic  consti- 
tution. Not  uncommonly  the  symptoms  first  make  their  ap- 
pearance after  mental  shock  or  following  trauma.  Cases 
belonging  to  the  latter  group  are  frequently  of  considerable 
forensic  importance.  Hysterical  symptoms  are  often  noted 
in  the  early  stages  of  various  forms  of  alienation,  such  as 
mania,  dementia  prsecox,  dementia  paralytica,  and  are  not 
uncommon  in  all  forms  of  toxaemia,  particularly  those  due 
to  alcohol,  lead,  morphin,  cocain,  and  other  poisons.  Great 
care  should  be  observed,  however,  in  affirming  that  the  symp- 

13  Sollier :    Guide  pratique  des  maladies  mentales.     Paris,  1893. 
u  Bruns,  L. :    Die  Hysterie  im  Kindesalter.    Halle,  1897. 
15  De  Fleury.     Contributions  a  l'etude  de  l'hysterie  senile.     Bordeaux^ 
1890. 


510  PSYCHIATRY 

toms  are  always  the  result  and  not  the  cause  of  the  addiction 
to  alcohol.  This  fact  is  of  great  importance  in  connection 
with  the  genesis  of  the  various  drug  habits  which  not  infre- 
quently develop  in  individuals  upon  an  hysterical  basis. 

Differential  Diagnosis. — The  hysterical  states  not  in- 
frequently develop  during  the  prodromal  periods  of  various 
psychoses.  When  this  is  the  case  the  positive  diagnosis  can 
be  established  only  after  the  other  more  specific  symptoms  have 
become  more  prominent.  These  cases  must  be  carefully  distin- 
guished from  those  in  which  the  hysterical  symptoms  are  more 
or  less  stable  and  which  are  not  complicated  by  those  of  other 
forms  of  alienation.  The  differentiation  of  hysteria  from  neu- 
rasthenia is  frequently  difficult.  As  a  rule,  the  occurrence  of 
the  hysterical  anaesthesias  or  the  various  forms  of  paralyses 
gives  important  indications.  The  same  painful  points  on 
pressure  may  be  found  in  both  instances,  but  in  hysterical 
states  they  are  apt  to  preponderate  on  one  side  of  the  body 
and  bear  some  definite  relationship  to  the  changes  in  the  cuta- 
neous sensation.  The  essential  difference  in  the  mental  states 
in  the  two  diseases  has  been  discussed  at  length  not  only  in 
the  present  chapter,  but  also  in  the  one  dealing  with  neuras- 
thenic states. 

In  the  early  stages  of  dementia  prcecox  we  not  infrequently 
meet  with  a  series  of  hysterical  symptoms,  and  it  is  only  when 
certain  distinctive  manifestations — such  as  catatonic  periods  of 
excitement  and  depression,  the  stereotypies,  mannerisms,  or 
negativism — make  their  appearance  that  the  diagnosis  can  be 
arrived  at  with  certainty.  The  importance  of  the  so-called  ir- 
relevancy in  dementia  prsecox  (Vorbeireden,  Danebenantwor- 
ten  16 )  has  been  alluded  to  elsewhere.  When  this  symptom  is 
pronounced  the  patients  are  unable  to  answer  correctly  ques- 
tions of  the  simplest  character,  although  they  generally  give 
indications  that  the  sense  is  rightly  apprehended.  Nissl's 
view  that  the  occurrence  of  irrelevancy  always  indicates  the 
existence   of  dementia   prsecox   needs    further   substantiation, 

16  Ganser :    Loc.  cit.     Moeli :    Ueber  irre  Verbrecher.     Berlin,  1888. 


HYSTERIA  511 

inasmuch  as  a  number  of  competent  observers  have  recorded 
its  presence  in  the  severer  forms  of  hysteria  and  particularly 
in  the  hysterical  disturbances  of  consciousness  following 
trauma.  Frequently  the  hysterical  dream  states  or  periods  of 
hallucinatory  mania  give  rise  to  great  difficulties  in  differen- 
tiation. Here  the  past  history  of  the  patient  is  of  the  greatest 
importance,  particularly  the  occurrence  of  paroxysmal  attacks 
of  crying,  the  characteristic  emotional  disturbances,  as  well  as 
the  appearance  of  anaesthesias,  various  forms  of  paralyses,  and, 
finally,  the  sudden  clearing  up  of  the  symptoms  after  they  have 
existed  for  a  considerable  period  of  time.  A  comparatively 
large  number  of  cases  of  manic-depressive  insanity  have  been 
mistaken  for  various  hysterical  states.  Here  a  previous  knowl- 
edge of  the  patient's  history  is  of  the  greatest  importance.  The 
diagnosis  is  more  difficult  in  the  milder  forms  where  the  motor 
restlessness,  the  flight  of  ideas,  and  general  exhilaration  char- 
acteristic of  the  manic  state  are  not  well  developed.  Such 
individuals  not  infrequently  present  a  variety  of  manifestations, 
such  as  painful  points  on  pressure,  psychic  anaesthesias,  and  dis- 
turbances in  the  mental  faculties,  which  to  the  casual  observer 
seem  to  correspond  with  those  of  the  maniacal  stage.  The 
diagnosis  depends  somewhat  on  the  manner  in  which  the  symp- 
toms progress.  The  absence  of  definite  hysterical  manifesta- 
tions, such  as  paralyses  or  hysterical  convulsions,  are  of  con- 
siderable significance.  The  flight  of  ideas  in  the  mild  cases, 
influenced  as  it  is  by  both  external  and  internal  stimulation, 
is  decidedly  different  from  the  psychical  symptoms  of  the  hys- 
terical individual,  in  which  the  vivid  play  of  the  imagination 
is  far  more  striking  than  the  immediate  response  of  the  patient 
to  the  various  kinds  of  stimuli.  The  depression  in  the  manic- 
depressive  psychoses  is  essentially  different  from  the  hypo- 
chondriacal egocentric  character  of  the  depressed  hysterical  in- 
dividual. The  marked  emotional  outbreaks  of  the  latter  usu- 
ally stand  in  direct  contrast  to  the  state  of  the  patient  in  whom 
the  objective  symptoms  of  depression  are  more  striking  and 
are  unaccompanied  by  any  evidence  of  a  more  general  anoma- 
lous emotional  state.     The  occurrence  of  marked  psychomotor 


5i2  PSYCHIATRY 

retardation  is  more  or  less  specific  of  the  depressed  stage  of  the 
recurrent  psychosis. 

The  diagnosis  between  the  hysterical  states  and  epilepsy 
is  often  beset  with  many  difficulties.  In  the  present  chapter 
reference  can  only  be  made  to  the  signs  that  are  of  diagnostic 
importance  in  attempting  to  differentiate  between  the  psychic 
equivalents  in  the  two  disorders.  The  history  of  the  onset  of 
the  attack  is  of  considerable  importance.  In  hysteria  the  prod- 
romal symptoms  are  apt  to  be  much  more  intense  and  well  de- 
fined, and  the  so-called  abdominal  aurse  are  more  prominent 
than  in  epilepsy.  The  loss  of  consciousness  in  epilepsy  is  much 
more  apt  to  be  sudden  and  complete,  and  during  this  period  the 
patient  is  frequently  insensitive  towards  external  stimulation. 
The  hysterical  symptoms  during  the  attack  may  be  intensified 
by  additional  stimuli  from  without,  and  such  patients  are  open 
to  various  forms  of  suggestion.  The  memory  defect  in  hysteria 
is  much  more  apt  to  be  only  partial,  and  the  events  which  have 
occurred  during  the  attack  may  frequently  be  recalled  to  the 
hysterical  patient,  particularly  under  the  influence  of  sugges- 
tion. 

A  few  cases  are  reported  in  the  literature  in  which  in  the 
early  stages  of  the  disease  symptoms  of  paresis  were  masked 
by  various  hysterical  manifestations.  Thus,  one  writer  noted 
the  occurrence  of  astasia,  anaesthesia  of  the  left  leg,  loss  of 
smell  and  taste.  These  symptoms  were  greatly  improved  by 
the  use  of  the  faradic  current,  but  later  others  specific  for  pare- 
sis made  their  appearance.  Sometimes  there  is  difficulty  in 
distinguishing  the  hysterical  attacks  from  those  of  an  apoplec- 
tiform character  occurring  in  the  earlier  stages  of  general 
paresis.  The  appearance  of  symptoms  which  are  dependent 
upon  the  existence  of  organic  lesions,  such  as  impairment  in 
the  light  reflex,  speech  disturbances,  etc.,  at  once  establishes  the 
diagnosis. 

Treatment. — The  suggestions  that  have  already  been 
made  with  reference  to  the  education  of  neuropathic  children 
apply  with  equal  force  to  those  in  whom  symptoms  of  hysteria 
make  their  appearance  early  in  life.     Although  it  is  necessary 


HYSTERIA 


513 


that  all  forms  of  coddling  should  be  scrupulously  avoided,  there 
is  no  indication  for  going  to  the  other  extreme  and  attempting 
under  the  present  conditions  of  life  to  train  children  according 
to  Spartan  methods.  The  giving  of  very  cold  baths  to  nervous 
children,  dressing  them  with  insufficient  clothing,  making  them 
go  about  with  bare  legs  and  feet,  or  not  allowing  them  to  wear 
hats  in  cold  weather  are  injurious  fads.  Such  children  need  a 
regular  life  free  from  the  excitement  that  follows  either  mental 
or  physical  over-exertion.  It  should  never  be  forgotten  that 
too  severe  physical  exercise  occasionally  produces  results  as 
unfortunate  as  those  following  mental  excesses.  No  definite 
rules  can  be  laid  down,  but  the  most  important  principle  to 
inculcate  upon  parents  and  teachers  is  that  the  education  of 
nervous  children  should  be  entrusted  only  to  those  who  them- 
selves possess  a  sound  mind  in  a  sound  body.  Great  care 
should  be  exercised  in  the  training  of  the  mental  faculties  of 
children  who  show  an  excessive  development  of  the  imagina- 
tion, for  although  this  faculty  plays  an  important  role  in  edu- 
cation no  less  than  in  the  maintenance  of  mental  and  physical 
vigor,  an  abnormal  tendency  to  read  only  fairy  tales,  ghost 
stories,  etc.,  should  be  as  far  as  possible  discouraged. 

The  treatment  of  hysterical  symptoms  in  the  adult  is  an 
undertaking  which  frequently  taxes  the  ingenuity  and  patience 
of  the  physician.  In  the  first  place,  the  latter  should  recognize 
the  importance  of  the  fact,  to  which  Dercum  and  others  have 
called  attention,  that  in  a  large  number  of  cases  there  is  marked 
evidence  of  a  general  disturbance  of  health.  The  necessity 
of  isolating  patients  who  are  suffering  from  attacks  of  hysteria 
and  placing  them  in  some  institution  where  they  will  be  under 
the  immediate  care  of  a  competent  physician  and  well-trained 
nurses  can  not  be  too  strenuously  urged.  In  some  few  instances 
among  patients  in  the  wealthier  classes  the  isolation  and  rest- 
cure  may  be  carried  out  at  home,  although  not  as  successfully 
as  in  a  first-class  hospital.  In  the  examination  of  the  patient 
it  is  of  great  importance  for  the  physician  not  to  dilate  too 
much  at  length  upon  the  individual  symptoms,  as  such  indi- 
viduals are  so  open  to  suggestion  that  not  infrequently  the  ex- 

33 


514  PSYCHIATRY 

amination,  unless  carefully  conducted,  may  lead  to  an  intensi- 
fication of  the  pain  in  certain  sensitive  areas  or  an  increase  in 
the  extent  of  an  existing  paralysis. 

Patients  suffering  from  the  severer  forms  of  hysteria,  as 
soon  as  the  examination  has  been  completed,  should  be  at  once 
put  to  bed  and  completely  isolated,  being  visited  only  by  the 
physician  in  charge  and  the  nurses.  On  no  account  is  it  advisa- 
ble to  permit  members  of  the  family  to  see  the  patient.  The 
rest  in  bed  should  be  at  first  continuous,  broken  only  by  the 
time  that  the  patient  spends  in  the  bath-tub  or  in  changing 
from  one  bed  to  another.  Various  hydrotherapeutic  measures 
are  of  great  use  in  the  treatment  of  hysteria,  sometimes  the 
pack  being  used  either  warm  or  cold,  and  in  other  instances  the 
prolonged  bath  (see  Chapter  V).  The  physician's  common- 
sense  and  judgment  must  tell  him  which  line  of  treatment  is 
the  most  efficacious,  as  individuals  vary  exceedingly.  The 
depression  may  be  greatly  benefited  by  the  cool  bath  or  pack, 
whereas  insomnia  may  be  combated  by  the  use  of  warm  water. 
Electricity  may  be  used  not  only  to  stimulate  the  muscles  in 
cases  of  paralysis,  but  also  to  relieve  pain.  Frequently  the 
faradic  current  or  static  electricity  is  of  some  benefit.  Com- 
bined with  the  rest  in  bed  the  patient  is  given  massage,  at  first 
once,  and  then  later  twice  or  even  three  times  a  day.  Care 
must  be  taken  not  to  increase  the  extent  of  any  painful  points, 
but  as  the  patient  becomes  less  sensitive  these  areas  also  may 
be  rubbed.  As  improvement  continues,  instead  of  massage 
various  forms  of  exercise,  especially  passive  movements,  may 
be  added.  The  exact  period  of  time  during  which  the  patient 
should  remain  in  bed  can  not  be  dogmatically  prescribed,  but, 
as  a  rule,  in  the  absence  of  other  contraindications,  it  is  well 
to  persist  in  this  procedure  until  the  emotional  instability  be- 
comes less  marked  and  the  general  tone  of  the  system  is  im- 
proved. Various  means  may  be  used  to  abort  the  hysterical 
paroxysms — sometimes  a  dash  of  cold  water  in  the  face,  the 
administration  of  valerianates,  asafcetida,  or  hypodermic  injec- 
tions of  distilled  water  may  be  resorted  to.  On  no  account 
should  either  the  nurse  or  the  physician  seem  to  attribute  too 


HYSTERIA 


515 


much  importance  to  the  seizures,  and  gradually  the  patient  may 
be  taught  to  control  them.  In  the  cases  of  individuals  who  are 
unable  to  go  to  a  hospital  and  where  the  paroxysms  are  only 
of  a  mild  character,  a  modified  rest-cure  may  be  instituted  at 
home,  provided  there  is  some  sufficiently  intelligent  member 
of  the  family  who  is  able  to  aid  the  physician  in  carrying  out 
the  directions. 


CHAPTER    XVIII 

NEURASTHENIC    AND    PSYCHASTHENIC    STATES  * 

Since  Beard  first  described  neurasthenia  the  groups  of 
symptoms  included  under  this  head  have  provided  a  field  for 
numerous  investigations  by  alienists  and  neurologists.  The 
disease  is  described  by  many  clinicians  as  a  psychopathic  con- 
dition characterized  by  (i)  abnormal  mental  and  physical  fa- 
tigue, (2)  impairment  of  the  associative  memory,  and  (3) 
sensory  disturbances  of  psychic  origin.  The  individual  symp- 
toms are  liable  to  considerable  variation,  and  those  to  be  de- 
scribed seldom  present  an  equal  prominence  in  any  one  case. 
Dutil  2  and  others  maintain  that  it  is  possible  to  distinguish 
between  the  more  or  less  stable  mental  states  in  which  the  neu- 
rasthenic symptoms  of  fatigue,  instability,  abulia,  and  depres- 
sion are  more  or  less  constant  and  a  variable,  episodic  state, 
folie  neurastheniqiie,  in  which  impulsivity,  obsessions,  and  pho- 
bias recurring  with  some  degree  of  periodicity  dominate  the 
clinical  picture.  Certain  writers,  more  particularly  Janet  and 
Raymond,  would  regard  both  series  of  symptoms  as  represent- 
ing one  and  the  same  disease,  and  include  under  the  head  of 
psychasthenia  a  large  group  of  cases  characterized  by  the  ordi- 
nary neurasthenic  symptoms,  as  well  as  the  various  forms  of 
obsessions,  impulses,  phobias,  tics,  mild  deliriums,  states  of 
apprehensiveness,  and  the  subsequent  defects  in  character  which 
develop  as  a  result  of  these  phenomena.  According  to  this 
classification,   therefore,  psychasthenia  would,  as  a  result  of 

1  Von  Kraff  t-Ebing :  Nervositat  u.  neurasthenische  Zustande.  Wien, 
1895.  Binswanger :  Pathologie  u.  Therapie  der  Neurasthenic  Jena,  1896. 
Ganser :  Die  neurasthenische  Geistesstorung.  1899.  I.  Janet,  II.  Janet  et 
Raymond  :  Les  Obsessions  et  la  Psychasthenic.  Paris,  1903.  Loewenfeld : 
Die  psychischen  Zwangserscheinungen.  Wiesbaden,  1904.  Wollenberg : 
Die  Hypochondrie.  Wien,  1904.  Dubois :  Les  psychonevroses  et  leur 
traitement  moral.     Paris,  1904. 

2  Dutil,  A. :    In  Ballet's  Traite  de  Pathologie  Mentale.     Paris,  1903. 

5i6 


NEURASTHENIC    STATES  517 

these  phenomena,  comprise  a  very  large  number  of  heteroge- 
neous cases,  including  such  complexes  as  the  "  degenerative 
psychoses,"  characterized  by  the  prominence  of  obsessional 
ideas  and  fears  (Zwangsvorstellungpsychosis),  the  impulsive 
insanity,  the  fright  psychoses,  as  well  as  the  milder  forms  of 
the  paranoiic  states — the  paranoia  rudimentaria  of  Morselli. 
Moebius  and  Dejerine  hold  that  the  neurasthenic  state  may 
properly  be  regarded  as  merely  an  initial  stage  out  of  which 
various  other  disturbances  develop,  while  Kowalewsky,  as 
long  ago  as  1887,  maintained  that  chronic  exhaustion  or  neu- 
rasthenia is  a  disease  of  the  nervous  system  that  in  its  milder 
forms  affects  chiefly  the  visceral  centres,  but  when  the  malady 
becomes  more  severe  gives  rise  to  the  clinical  picture  now  re- 
ferred to  as  psychasthenia.  Janet  thinks  that  psychasthenia  has 
many  features  in  common  with  epilepsy,  and  the  former  is  re- 
ferred to  as  if  it  were  merely  a  mild  but  chronic  representation 
of  the  latter.  Clinically,  psychasthenia  occupies  a  median  posi- 
tion between  epilepsy  on  the  one  side  and  hysteria  on  the 
other.  According  to  Janet,  the  representations  in  consciousness 
in  the  psychasthenic  are  endogenous  and  relate  to  persons  or 
objects  in  the  patient's  environment,  while  in  hysteria  the  no- 
tions that  occupy  the  attention  are  exogenous  in  origin  and 
the  result  of  suggestion  or  emotional  disturbances. 

As  this  classification  in  a  measure  facilitates  description, 
it  has  been  adopted  here,  although  with  the  evidence  at  hand 
it  must  be  regarded  only  as  a  strictly  provisional  expedient.  In 
the  first  category  falls  the  group  of  cases  commonly  described 
as  chronic  nervous  exhaustions,  and  in  the  second  those  in 
which  the  symptoms  have  a  tendency  to  change  and  recur  with 
some  degree  of  periodicity.  For  the  sake  of  convenience  we 
shall  here  designate  the  former  condition  as  neurasthenia  and 
the  latter  as  psychasthenia. 

A  sharp  differentiation  between  chronic  nervous  exhaus- 
tion— the  secondary  or  acquired  form — from  the  so-called  con- 
genital type  of  the  disease,  although  possible  in  many  instances, 
is  in  others  met  by  serious  difficulties.  It  must  be  borne  in 
mind  that  the  two  groups  of  cases  frequently  blend  and  that 


518  PSYCHIATRY 

the  distinction  is  made  more  as  an  aid  to  description  than  be- 
cause of  the  existence  of  any  fundamental  reason  which  would 
justify  this  division.  Levillain  directed  attention  to  the  neu- 
rasthenic states  occurring  in  hereditarily  predisposed  individ- 
uals and  which  make  their  appearance  early  in  life,  becoming 
accentuated  at  or  about  puberty  and  characterized  by  a  variety 
of  mental  stigmata  principally  in  the  emotional  and  intellectual 
spheres,  the  patients  belonging  to  the  large  group  of  individuals 
referred  to  by  Magnan  as  "  desequilibres." 

In  passing,  it  is  well  to  note  that  a  clinical  distinction  may 
reasonably  be  drawn  between  the  cases  of  cerebral  neurasthenia, 
or  cerebrasthenia,  which  have  a  progressive  tendency  and  in 
reality  represent  the  prodromal  period  of  certain  organic  dis- 
eases,— e.g.,  dementia  paralytica,  senile  dementia,  dementia 
praecox, — and  the  uncomplicated  and  more  or  less  stable  neu- 
rasthenic states.3 

Clinical  Symptoms. — These  will  be  described  under  two 
separate  groups :  ( i )  Those  that  are  more  or  less  stable ;  (  2  ) 
those  that  have  a  tendency  to  become  variable  and  episodic. 

A.  Neurasthenic  States. — As  has  already  been  stated, 
fatigue,  both  mental  and  physical,  is  a  cardinal  symptom  in 
neurasthenia.  This  is  shown  in  many  ways.  Neurasthenics 
are  wont  to  complain  that  every  effort  gives  rise  to  a  sense 
of  fatigue,  the  expression  of  which  is  largely  subjective,  inas- 
much as  such  individuals  may  under  sufficient  stimulus  be  made 
to  exercise  considerable  effort,  although  as  soon  as  the  inciting 
factor  is  withdrawn  they  return  immediately  to  their  former 
condition.  This  sense  of  weariness  not  only  limits  the  execu- 
tion of  volitional  acts,  but  also  impairs  the  intellectual  proc- 
esses, any  attempt  to  continue  a  line  of  connected  thought 
being  accompanied  by  an  abnormal  sense  of  effort.  Moreover, 
the  patients  frequently  affirm  that  the  more  they  struggle  to 
throw  off  this  mental  inertia  the  more  rapidly  does  the  feeling 
of  fatigue  become  intensified. 


a  Schaffer :     Anatomisch-klinische  Vortrage  aus  dem  Gebiete  der  Ner- 
venpathologie.    Jena,  1901. 


NEURASTHENIC   STATES  519 

An  excellent  method  of  demonstrating  this  fatigue  in 
neurasthenics  has  been  proposed  by  Weygandt.  The  patients 
are  asked  to  add  up  columns  of  figures  and  give  their  results 
within  a  certain  time  limit.  In  normal  individuals  during  the 
second  or  fourth  quarter  of  an  hour  during  which  the  experi- 
ment is  carried  on  there  is  a  definite  increase  in  the  facility 
with  which  the  additions  are  made,  whereas  in  the  neuras- 
thenic the  inability  to  focus  the  attention,  shown  by  the  increase 
in  the  number  of  errors  in  the  additions,  rapidly  makes  its 
appearance.  By  this  method  we  may  construct  two  curves  rep- 
resenting graphically  the  contrast  between  the  normal  and  the 
abnormal  individual. 

For  sudden  and  spasmodic  effort  there  is  no  diminution 
in  the  dynamic  power  of  the  muscles,  but  this  quickly  falls  if 
the  strain  is  prolonged.  The  ease  with  which  these  patients 
are  tired  out  is  revealed  in  the  limitation  of  the  volitional  proc- 
esses, and  the  more  complicated  the  chain  of  muscular  move- 
ments undertaken  the  more  evident  does  this  become.  In  very 
exaggerated  cases  the  patients  complain  that  they  are  unable 
even  to  raise  a  limb,  and  remain  for  days  and  weeks  in  bed 
unless  compelled  to  exert  themselves.  The  mere  thought  of 
being  placed  in  a  position  where  the  expenditure  of  effort  is  un- 
avoidable frequently  causes  great  mental  distress.  In  addition 
to  the  subjective  sense  of  fatigue  accompanying  physical  and 
mental  effort,  we  meet  with  a  variety  of  sensory  disturbances 
that  may  also  condition  the  inertia,  for  it  is  not  improbable,  as 
Ziehen  has  suggested,  that  the  evident  disinclination  to  move 
is  referable  in  part  to  hyperalgesias  or  hyperesthesias.  Neu- 
rasthenic patients,  as  a  rule,  seem  abnormally  sensitive  to  all 
forms  of  stimuli,  each  new  stimulus  causing  an  apparent 
radiation.  For  example,  a  bright  light  impinging  on  the  retina, 
in  addition  to  the  immediate  discomfort,  sometimes  gives  rise 
to  photophobia  or  to  a  whole  chain  of  nervous  symptoms.  As 
a  rule,  the  patients  show  a  hyperesthesia  of  one  or  more  senses, 
resembling  those  noted  in  hysteria — hyperesthesia  retinae, 
hyperacusis,  and  hyperosmia.  Closely  associated  with  these 
psychic  hyperesthesias  is  the  fear  of  pain  which  is  frequently 


520  PSYCHIATRY 

so  characteristic  and  may  give  rise  to  states  of  mental  anguish 
similar  to  those  described  by  Mobius  under  the  head  of  akinesia 
algera.  Such  patients  frequently  express  themselves  as  being 
unable  to  tolerate  the  mildest  irritant  without  becoming  ex- 
cessively nervous  and  emotional.  On  actual  pressure  various 
parts  of  the  body  frequently  seem  to  be  the  seat  of  pain. 

The  psychic  hyperesthesias  in  neurasthenics  are  referred 
to  by  Blocq  4  as  topoalgias,  and  are  characterized,  according 
to  him,  by  the  persistence  of  a  painful  sensory  memory,  a 
phenomenon  that  bears  to  the  sensory  functions  a  relation  anal- 
ogous to  that  of  the  fixed  idea  to  the  intellectual  processes. 
Not  infrequently  these  pains  are  referred  to  the  head  and  neck, 
to  various  regions  in  the  chest — particularly  the  precordial  or 
epigastric — as  well  as  to  the  extremities.  The  pain  seems  to 
appear  spontaneously,  and  when  occurring  in  the  head  is  de- 
scribed not  as  a  definite  headache,  but  rather  as  a  more  or  less 
indescribable  feeling  of  an  unpleasant  nature.  Various  unpleas- 
ant cutaneous  sensations  often  appear  which  may  be  associated 
with  emotional  anomalies,  such  as  the  so-called  acarophobia 
and  other  forms  that  will  be  described  later  on.  The  pains 
may  be  either  diffuse  or  localized,  and  are  more  apt  to  be  sym- 
metrical in  their  distribution  than  is  the  case  in  hysteria. 

Sensory  disturbances  in  connection  with  the  sexual  organs 
are  not  uncommon.  These  give  rise  to  para-  or  hyperesthe- 
sias that  play  an  important  part  as  causes  of  masturbation,  ex- 
cessive intercourse,  and  the  production  of  the  whole  chain  of 
subsequent  nervous  and  mental  symptoms  belonging  to  the 
so-called  sexual  neurasthenias.  Sexual  pollutions  frequently 
occur  in  neurasthenics  and  may  aggravate  the  already  existing 
mental  symptoms,  but  these  are  never  to  be  considered  of 
primary  etiologic  importance,  being  the  result  and  not  the 
cause  of  the  disease.  Such  painful  sensations  in  women  are 
apt  to  be  of  greater  importance  than  in  men,  as  they  may  lead 
the  patient  to  insist  upon  the  removal  of  the  ovaries,  uterus, 
or  clitoris. 

4  Gaz.  hebd.  de  med.  et  de  chir.,  Mai,  1891. 


NEURASTHENIC    STATES  521 

In  addition  to  the  hyperesthesias,  we  frequently  meet  with 
a  great  variety  of  paresthesias.  Many  patients  complain  of 
curious  sensations  in  the  extremities,  of  seeing  flashes  of  light, 
of  hearing  indefinite  sounds.  Various  forms  of  pruritus  may 
develop  and  cause  excessive  annoyance.  As  a  rule,  the  dis- 
turbances in  the  cortical  centres  give  rise  to  only  elementary 
hallucinations  except  in  the  case  of  the  visual  centre.  Neuras- 
thenics sometimes  complain  of  seeing  visions  and  faces  when 
the  eyes  are  closed,  but  these  disappear  when  the  eyes  are 
opened  and  the  subjective  character  of  the  phenomena  is  at 
once  recognized  by  the  patient.  Numerous  observers  main- 
tain that  the  hallucinations  in  neurasthenia,  as  contrasted  with 
those  in  hysterical  crises,  never  develop  completely,  since  the 
mental  representations  remain  imperfect  and  therefore  do  not 
dominate  the  subsequent  acts  of  the  patients.  Further  refer- 
ence will  be  made  to  this  subject  later  on  when  the  episodic 
symptoms  are  described. 

The  mental  characteristics  of  the  neurasthenic  are  very 
varied.  As  has  already  been  pointed  out,  distractibility  is 
usually  somewhat  marked,  so  that  the  focus  of  attention  is  con- 
stantly changing,  and  any  attempt  on  the  part  of  an  individual 
to  fix  it  for  a  given  length  of  time  is  accompanied  by  an  ab- 
normal sense  of  effort.  These  fluctuations  are  largely  account- 
able for  the  amnesias.  The  patients  complain  that  they  cannot 
recollect  even  the  simplest  occurrences  or  events  of  their  daily 
life — a  fact  that  often  distresses  them  exceedingly  and  gives 
rise  to  marked  emotional  disturbances,  as  well  as  increasing 
their  sense  of  insufficiency.  Frequently,  when  an  extra  effort 
is  made  to  remember  certain  ideas  or  events,  there  is  not  only 
the  immediate  discomfort  caused  by  the  increased  expenditure 
of  energy,  but  the  failure  intensifies  the  emotional  outbreak, 
so  that  the  patients  are  apt  to  become  very  despondent  and 
possessed  by  various  hypochondriacal  ideas.  The  irritability 
of  the  neurasthenic  has  already  been  referred  to.  External 
stimuli  of  all  forms  seem  at  times  to  be  an  acute  annoyance. 
Occasionally,  without  apparent  provocation,  such  individuals 
become  angry  or  morose,  and  the  exaggerated  sense  of  con- 


522 


PSYCHIATRY 


trition  and  penitence  that  follows  is  almost  sure  to  be  super- 
seded by  mental  depression.  Although  neurasthenics  may  at 
times  find  an  excessive  enjoyment  in  objects  or  events  of  a 
pleasurable  nature,  they  are  prone  to  become  easily  depressed, 
a  feeling  which  is  intensified  as  soon  as  any  effort  meets  with 
opposition. 

Under  the  head  of  chronic  nervous  exhaustion  may  be 
included  the  group  of  cases  described  by  some  authors  as  in- 
stances of  constitutional  depression  (constitutionelle  Verstim- 
mung).  This  condition  is  more  apt  to  occur  in  individuals 
who  show  a  remarkable  mental  development  along  certain  lines 
but  a  deficiency  in  others.  Such  persons  not  infrequently  are 
enthusiastic  and  earnest  in  beginning  any  new  work,  but  are 
easily  fatigued  and  discouraged.  As  a  rule,  they  suffer  from 
a  variety  of  symptoms,  and  are  particularly  subject  to  hypo- 
chondriacal attacks.  They  are  frequently  more  or  less  cynical, 
seldom  finding  anything  in  life  from  which  to  derive  much 
encouragement,  and  continually  looking  upon  the  dark  side  of 
every  question.  In  the  higher  classes  of  society  these  individ- 
uals are  generally  recognized  as  cynics  and  pessimists,  are 
much  given  to  reflection,  and  are,  as  a  rule,  excessively  in- 
trospective.5 As  Maudsley  has  pointed  out,  this  group  of 
cases  not  infrequently  includes  individuals  of  great  intellectual 
attainments  but  who,  on  account  of  their  mental  state,  are  none 
the  less  deficient  in  the  power  of  leadership  or  organization. 
The  psychic  tonus  of  these  individuals  is  altered,  and  this  de- 
terioration is  reflected  in  their  whole  emotional  life.6  Many 
of  these  cases  were  formerly  described  under  the  head  of 
melancholia,  but  are  to  be  differentiated  by  the  absence  of 
insane  ideas,  self-accusation,  as  well  as  by  the  sudden  changes 
in  the  affective  display.  In  many  of  these  individuals  the  ap- 
pearance in  consciousness  of  an  unpleasant  thought  gives  rise 
to  a  feeling  of  depression  which  may  persist  for  several  hours. 

8  Kowalewski,  Arnold :  Studien  zur  Psychologie  des  Pessimismus. 
Wiesbaden,  1904. 

6  Pick,  A. :  Zur  Psychopathologie  der  Neurasthenic  Arch.  f.  Psych. 
u.  Nervenkrankheiten,  Bd.  xxxv,  1902. 


PSYCHASTHENIC    STATES  523 

In  the  neurasthenic,  as  distinguished  from  the  patient  suffering 
from  true  melancholia,  we  find  that  the  conditions  of  irrita- 
bility associated  with  apprehensiveness  are  largely  influenced 
by  external  impressions  and  ideas. 

The  emotional  state  may  vary  from  one  in  which  there 
is  merely  a  vague  sense  of  discomfort  to  one  in  which  there 
is  an  exaggerated  sense  of  mental  depression  or  anguish.  As 
a  result  of  these  tendencies,  all  of  which  centralize,  the  patient's 
interests  become  more  and  more  egotistical.  In  some  instances 
there  is  marked  hypochondriasis  and  an  elimination  from  con- 
sciousness of  all  ideas  not  relating  to  the  individual  needs  and 
interests.  Such  patients  can  only  talk  and  think  about  them- 
selves or  about  matters  in  which  they  have  an  immediate  in- 
terest, and  eventually  become  incapable  of  any  degree  of 
altruism. 

B.  Psychasthenic  States. — Prominent  among  the  episodic 
syndromes  are  the  various  forms  of  obsessional  ideas  and  im- 
pulses. As  was  pointed  out  in  the  introductory  section,  these 
ideas  are  frequently  abstract  in  nature  and  exceedingly  com- 
plicated in  their  pathogenesis.  They  include  many  different 
forms,  of  which  only  the  more  common  types  will  be  referred 
to  here.  Chief  among  these  are  the  hypochondriacal  obses- 
sions, all  of  which  tend  to  make  the  individuals  self-centred  and 
abnormally  sensitive  in  regard  to  their  physical  ailments. 
Sometimes  their  attention  seems  to  be  riveted  upon  certain 
organs.  A  slight  palpitation  suggests  the  idea  that  they  have 
organic  heart  disease,  and  in  spite  of  repeated  assurances  to 
the  contrary  from  competent  physicians  they  adhere  most  tena- 
ciously to  their  autodiagnosis.  In  other  instances  the  obses- 
sions are  referred  to  the  genital  organs.  A  slight  herpes  or 
eczema  is  sufficient  ground  for  believing  that  they  are  infected 
with  syphilis.  Ideas  regarding  impending  death  or  the  onset 
of  various  chronic  maladies — such  as  phthisis  or  blindness — 
are  repeatedly  forced  upon  their  attention.  A  slight  cough  is 
regarded  as  a  sure  sign  of  pulmonary  tuberculosis;  pains  in 
the  legs  become  the  initial  symptoms  of  locomotor  ataxia;  a 
mild  degree  of  nausea  and  vomiting  carries  with  it  a  premoni- 


524  PSYCHIATRY 

tion  of  gastric  carcinoma,  etc.  Frequently  these  fixed  ideas 
are  related  not  only  to  the  personality  of  the  individual,  but  to 
his  environment,  as  well  as  to  his  social  relationships.  Fre- 
quently neurasthenics  suffer  from  an  excessive  form  of  shy- 
ness shown  in  attacks  of  recurrent  and  excessive  embarrass- 
ment. Such  individuals  are  continually  plagued  by  the  idea 
that  whatever  they  do  or  say  is  regarded  as  improper.  They 
affirm  continually  that  when  among  strangers  they  are  ill  at 
ease,  unable  to  carry  on  a  conversation,  that  their  wits  leave 
them,  so  that  all  forms  of  social  duties  pall  upon  them. 

The  imperative  ideas  or  obsessions  (Zwangsvorstel- 
lungen)  are  associated  with  the  so-called  imperative  processes, 
of  which  there  is  a  large  variety.  The  mental  states  in  which 
these  are  the  dominating  symptom  have  been  described  by 
Donath,  of  Budapest,7  as  anarchasma.  The  intrusion  of  these 
irrepressible  ideas  into  consciousness  often  gives  rise  to  a  great 
variety  of  mental,  motor,  and  emotional  anomalies.  Among 
the  first  are  the  various  questions  which  the  patient  frequently 
feels  impelled  to  ask  (folie  du  pourquoi).  These  in  a  great 
many  cases  refer  to  the  patient's  own  condition,  but  not  infre- 
quently relate  to  objects  quite  outside  of  the  personality.  The 
absence  of  motive  renders  it  not  at  all  improbable  that  these 
interrogations  are  similar  to  the  "  whys  and  wherefores"  of 
children.  Not  uncommonly,  especially  in  the  intellectual  class 
of  patients,  this  interrogatory  mood  drives  them  to  the  dis- 
cussion of  abstruse  themes.  They  feel  themselves  compelled 
to  spend  much  time  in  debating  why  God  made  the  world, 
why  they  were  put  on  the  earth,  the  origin  of  right  and  wrong, 
and  various  other  metaphysical  inquiries.  It  is  not  at  all  im- 
probable, as  Royce  has  pointed  out,  that  John  Bunyan  suffered 
from  this  form  of  mental  agitation ;  and  Rousseau  in  his 
"  Confessions"  admits  that  he  was  often  greatly  troubled  by 
speculations  as  to  the  nature  of  Hell.  These  types  are  closely 
akin  to  those  described  by  Legrand  du  Saule  and  other  French 
writers  as  "  mental  rumination."     In  such  cases  a  long  train 

7  Arch.   f.   Psych,   1896. 


PSYCHASTHENIC    STATES  525 

of  connected  ideas  occupies  the  field  of  attention,  so  that  the 
individual  can  not  break  away  from  them  and  is  frequently 
obliged  to  continue  a  particular  line  of  thought  to  the  bitter 
end.  Not  infrequently  phenomena  of  this  character  are  most 
insistent  at  night  and  form  one  of  the  important  causes  of  in- 
somnia, from  which  neurasthenics  so  frequently  suffer.  The 
same  is  true  of  the  so-called  forced  reveries  into  which  neuras- 
thenics are  frequently  thrown  and  from  which  they  have  the 
greatest  difficulty  in  freeing  themselves. 

Frequently  psychasthenics  give  objective  expression  to 
their  impellent  ideas  by  eccentricities  of  manner  and  character. 
Such  individuals  not  infrequently  waste  a  great  deal  of  time 
in  "  putting  things  in  order."  Rest  is  impossible  if  a  book  or 
any  object  about  the  room  is  out  of  its  proper  place.  The 
mania  for  the  preservation  of  order  is  particularly  noticeable 
in  young  neurasthenic  mothers,  who  cannot  bear  to  see  their 
children's  clothing  disarranged  or  their  hands  or  faces  dirty 
even  while  at  play.  The  first  idea  that  strikes  their  attention 
is  not  the  comfort  and  health  of  the  child,  but  rather  that  they 
must  always  be  scrupulously  clean  and  well  dressed.  Fre- 
quently neurasthenics  feel  obliged  to  count  or  to  work  out 
problems — arithmomania — or  express  their  preference  for  cer- 
tain numbers  which  they  feel  obliged  to  repeat,  sometimes  to 
pronounce  aloud.  Similar  conditions  are  noticeable  in  the 
states  of  fatigue  following  exhaustion,  after  fevers,  trauma, 
etc.,  when  the  sufferers  will  tell  us  that  they  are  impelled  to 
count  the  figures  on  the  wall,  the  books  in  the  book-case,  ob- 
jects about  the  room,  and  to  continue  this  operation  until  ex- 
hausted. In  the  condition  described  by  Charcot  and  Magnan 
as  onomatomania  8  the  patient  feels  obliged  to  recall  a  certain 
name  or  names  which  have  once  been  noticed,  not  infrequently 
spending  considerable  time  and  energy  in  going  to  some  out- 
of-the-way  street  to  find  a  certain  board  once  casually  noticed 
in  passing.  Sometimes  patients  affirm  that  without  cause  they 
are  compelled  to  swear  and  blaspheme.    This  sometimes  occurs 

8  Arch,  de  Neurologie,  September,  1885. 


526  PSYCHIATRY 

in  young  girls  or  in  individuals  in  whom  the  phenomenon  is 
equally  extraordinary. 

In  many  of  the  psychasthenic  states  we  meet  with  a  variety 
of  tics.  These  anomalies  of  movement,  as  Charcot  pointed 
out,9  are  the  caricature  of  natural  acts.  These  various  move- 
ments may  be  provisionally  classified,  not  according  to  the 
groups  of  muscles  affected,  but  rather  by  the  act  of  which  the 
tic  is  the  caricature;  for  example,  tics  of  the  mouth,  of  the 
eyelids,  respiratory  tics,  tics  of  attitude,  etc.10 

The  emotional  disturbances  associated  with  anomalies  of 
ideation  and  motion  are  also  varied.  Various  classifications 
of  the  fears  to  which  the  psychasthenic  individuals  are  subject 
have  been  attempted.  Freud  makes  three  categories :  ( i ) 
the  traumatic  phobias  (more  common  in  hysteria)  ;  (2)  an 
exaggeration  of  ideas  entertained  regarding  events  in  ordinary 
life,  such  as  fear  of  night,  solitude,  or  sickness;  (3)  fears  of 
place — agoraphobia,  etc.  Janet,  on  the  other  hand,  prefers  a 
four- fold  division  :  ( 1 )  fears  relating  to  the  body  and  deter- 
mined by  anomalies  of  sense  perception;  (2)  those  relating 
to  objects  outside  of  the  body;  (3)  those  of  situation  which 
are  not  determined  merely  by  the  perception  of  single  objects, 
but  rather  by  a  combination  of  circumstances;  (4)  the  fears 
pertaining  to  various  ideas.  Many  of  the  fears  in  the  somato- 
psychic field  of  consciousness  have  already  been  shown  to  be 
dependent  upon  the  psychic  hyperesthesias.  This  is  in  a  meas- 
ure true  in  regard  to  the  so-called  fears  of  function,  fears  of 
movement, — akinesia  algera, — and  the  acathisia  described  by 
Haskovec.11 

Instances  have  been  reported  in  which  the  person  has  had 
a  fear  of  speaking.  Psychasthenic  individuals  not  infrequently 
are  greatly  perturbed  by  the  various  phobias  associated  with 
the  processes  of  digestion.  They  believe  that  everything  that 
they  eat  disagrees  with  them,  that  their  food  does  not  nourish 


"Lemons  du  Mardi,  1888-89,  P-  464. 

10  Les  tics  et  leur  traitement.    Meige  et  Feindel,  Paris,  1902. 

"Haskovec:    L'akathisie.     Revue  neurologique,  30  Nov.,  1901. 


PSYCHASTHENIC    STATES  527 

them.  Sometimes  the  phobias  are  referred  to  various  internal 
organs  or  are  not  infrequently  excited  by  various  sensations, 
odors,  sounds,  etc.  Photophobia  is  not  an  uncommon  symp- 
tom. In  this  as  well  as  the  other  phobias  connected  with  the 
senses  the  peripheral  tract  is  intact,  and  in  individuals  who 
for  considerable  periods  of  time  have  been  afraid  to  venture 
into  the  light,  examination  has  shown  the  eyes  to  be  in  every 
way  normal.  Somewhat  more  complicated  are  the  fears  of 
touching  certain  objects, — delire  du  contact, — a  series  of  phe- 
nomena to  which  Esquirol  first  directed  attention.  These  in- 
clude the  cases  of  mysophobia  and  rupophobia. 

The  persistence  of  these  ideas  and  the  remarkable  reflex 
power  which  they  may  exert  over  the  conduct  of  the  patient 
are  well  shown  in  the  following  history : 

Female,  aged  33  years.  Married.  Came  to  Out-patient  Department, 
Johns  Hopkins  Hospital,  complaining  of  nervousness. 

Family  History. — Mother  extremely  neurotic,  paralyzed  before  she 
was  married,  also  hypochondriacal.  Father  dead;  was  said  to  have  been 
a  cripple. 

Personal  History. — Strong  and  healthy  baby.  When  3  years  old 
she  had  scarlet  fever;  has  been  nervous  ever  since.  Pneumonia  at  16. 
Married  at  19.  One  child,  13  years  old.  For  a  great  many  years 
the  patient  has  been  getting  more  and  more  nervous.  She  has  been 
troubled  with  headaches,  cold  feet  and  hands,  hot  flushes ;  indefinite  pains 
first  on  one,  then  on  the  other  side  of  the  body.  "  Sometimes  the  toes  of 
the  right  foot  were  stiff  and  paralyzed."  Several  years  ago  she  affirms 
that  she  was  deaf  in  the  right  ear.  Also  complains  of  poor  eyesight.  The 
family  physician  says  that  the  patient  has  had  several  attacks  which  in  a 
measure  suggested  epilepsy,  but  she  has  never  injured  herself  during  an 
attack  and  never  passed  her  urine  involuntarily,  although  after  the  last 
attack  the  quantity  was  greatly  increased.  Ten  years  ago  the  patient  began 
to  be  greatly  disturbed  by  the  presence  of  dust  in  her  room.  She  affirmed 
that  she  was  always  busy  cleaning.  She  used  to  dust  and  sweep  until  she 
was  worn  out.  She  recognized  that  this  excessive  cleanliness  was  fool- 
ish, but  said  that  ever  since  she  was  a  girl  in  school  she  has  been  over- 
particular about  her  personal  appearance  and  dress.  At  first  she  did  not 
think  that  her  efforts  at  excessive  neatness  and  tidiness  were  foolish,  but 
this  idea  gradually  dawned  upon  her.  While  in  the  Johns  Hopkins  Hos- 
pital for  operation — repair  of  laceration  following  labor — she  began  to  feel 
a  constant  craving  for  water  to  wash  her  hands  in,  and  used  to  beg  to  be 
allowed  to  hold  wet  rags  in  her  hands.  After  leaving  the  hospital  she  fre- 
quently felt  obliged  to  hold  her  hands  under  the  tap  in  the  kitchen.  At  first 
this  sufficed,  but  soon  she  began  to  think  that  this  flow  of  water  was  not 


528  PSYCHIATRY 

large  enough.  This  impulse  to  wash  her  hands  has  become  so  strong 
that  when  the  patient  tries  to  resist  it  she  frequently  breaks  down  and 
cries.  She  never  uses  warm  water,  but  always  cold.  The  symptoms  have 
become  so  distressing  that  the  patient  is  willing  to  do  anything  to  be 
cured,  as  she  says  the  impulses  at  present  are  so  strong  that  she  cannot 
possibly  resist  them.  She  also  declares  that  her  heart  gives  her  a  great 
deal  of  trouble — "  It  feels  as  big  as  my  head"  and  beats  very  rapidly. 
She  is  exceedingly  sensitive  to  noise  and  excitement  and  has  even  been 
obliged  to  have  the  door-bell  of  her  house  disconnected,  particularly  dur- 
ing the  period  of  menstruation.  Her  appetite  is  markedly  capricious. 
Sometimes  there  is  polyphagia,  when  she  bolts  her  food.  This  is  particu- 
larly marked  during  the  week  before  menstruation.  At  other  times  the 
patient  eats  very  little. 

Physical  Examination. — Medium  height,  poorly  nourished,  mucous 
membranes  somewhat  pale,  exceedingly  neurotic,  manner  unstable,  restless. 
At  first  she  was  somewhat  reserved  in  answering  questions,  but  as  soon 
as  the  ice  was  broken  she  became  loquacious  and  then  talked  a  perfect 
stream  about  herself.  No  defects  in  associative  memory  were  demonstra- 
ble. The  reflexes  were  all  slightly  exaggerated.  There  was  slight  ten- 
derness in  the  right  iliac  fossa. 

Thorax :    The  lungs  and  heart  were  normal. 

There  was  no  typical  flight  of  ideas,  no  marked  impulsivity.  The 
patient  was  very  emotional  and  solicitous  about  her  future,  feared  that 
she  would  never  recover,  became  depressed,  and  cried  easily  when  her 
thoughts  were  directed  along  this  line.  She  was  sent  to  the  Sheppard 
Hospital,  and  after  remaining  there  for  several  months  was  discharged 
unimproved. 

Agoraphobia, — the  so-called  fear  of  open  places, — an- 
other not  uncommon  symptom,  was  first  described  by  West- 
phal.12  Practically  speaking,  the  term  is  applied  not  to  an 
actual  fear  of  open  places,  as  the  name  would  indicate,  but 
rather  to  a  complex  series  of  phenomena  due  to  the  strange, 
indefinable  sensations  that  overwhelm  nervous  individuals 
when  brought  into  surroundings  with  which  they  are  unac- 
quainted and  where  they  feel  the  lack  of  that  physical  and 
moral  support  to  which  they  are  generally  accustomed. 

Claustrophobia — the  fear  of  closed  places — is  exhibited  in 
various  ways.  Thus  some  patients  are  conscious  of  a  vague 
sense  of  oppression  and  apprehensiveness  as  soon  as  they  enter 
a  public  building.     In  the  mild  cases  this  does  not  become  so 

12  Arch.  f.  Psych.,  H.  3,  1872. 


PSYCHASTHENIC    STATES  529 

apparent,  provided  that  the  sufferer  does  not  feel  that  he  is 
placed  in  a  position  whence  exit  is  difficult.  A  distressing  ten- 
dency to  blush  is  noted  in  many  psychasthenics,  and  is  often 
sufficiently  pronounced  to  make  the  patient  averse  to  going 
into  society.  In  the  exaggerated  cases  it  is  excited  whenever 
the  patient  encounters  a  stranger — eurotophobia.  This  term 
must  be  carefully  distinguished  from  erythrophobia,  or  the  fear 
of  a  red  color. 

Taphophobia — the  fear  of  being  buried  alive — is  also  not 
uncommon.  A  great  variety  of  other  phobias  have  been  de- 
scribed, but  need  not  be  mentioned  here,  since  details  can  be 
found  in  the  various  special  works  upon  the  subject. 

The  so-called  diffused  emotional  disturbances  are  of  fre- 
quent occurrence  and  some  patients  continue  in  a  state  of  anx- 
ious expectancy  for  considerable  periods  of  time  without  being 
able  to  assign  any  definite  cause  for  the  condition  or  to  control 
it.  This  symptom  varies  in  intensity  from  mere  timidity  to 
pronounced  apprehensiveness  and  anxious  expectancy  accom- 
panied by  tremor ;  it  is  associated  with  disturbances  in  the  cir- 
culation and  respiration,  and  in  some  instances  with  nausea, 
vomiting,  and  attacks  of  diarrhoea.  The  physiological  symp- 
toms noted  in  these  affective  disorders  have  been  referred  to 
more  in  detail  in  the  first  section  of  the  book. 

The  phobias,  obsessive  ideas,  and  impulses  are  particularly 
apt  to  recur  in  the  form  of  crises  in  which  the  emotional  dis- 
turbances are  greatly  accentuated  and  the  dominating  influ- 
ence of  the  anomalous  condition  in  some  instances  becomes 
overwhelming. 

The  obsessional  ideas  and  obsessional  impulses  cannot  be 
sharply  differentiated.  Although  in  all  cases  in  which  a  domi- 
nant idea  is  present  there  is  a  marked  tendency  towards  move- 
ment of  some  kind,  the  exact  instant  at  which  the  translation 
of  thought  into  action  takes  place  cannot  always  be  deter- 
mined by  the  observer.  For  example,  in  cases  in  which  the 
impellant  idea  is  one  that  arouses  a  sense  of  fear,  there  is  a 
marked  tendency  on  the  part  of  the  patient  to  show  this  in  his 
actions.     This  driving  power  is  dominant  in  all  forms  of  ob- 

34 


530  PSYCHIATRY 

sessions,  so  that  in  the  majority  of  cases  it  is  impossible  to 
affirm  that  an  idea  which  harasses  and  torments  the  patient  is 
not  sufficiently  tyrannical  to  cause  some  kind  of  movement,  al- 
though the  act  may  be  apparently  purposeless  and  not  directly 
related  to  any  motive.  The  obsessive  ideas  of  suicide,  so 
common  in  pure  psychasthenic  states,  are  seldom,  if  ever,  fol- 
lowed by  actual  self-destruction.  From  the  forensic  stand- 
point these  patients  may  be  considered  as  only  standing  on  the 
border-line  of  insanity.  In  order  that  the  impulsion  may  be 
sufficiently  strong  to  drive  the  individual  to  the  commission 
of  definite  crimes,  as  a  general  rule  there  must  be  superadded 
another  psychosis  complicating  the  psychasthenic  state.  The 
dominating  motive  force  of  these  impulses  is  materially  less 
than  in  hysterical  states,  with  the  exception  of  those  of  genital 
origin,  which  are  considered  by  most  authorities  to  be  capable 
of  dominating  the  volitional  processes.  Not  infrequently  ob- 
sessions of  this  nature  are  the  cause  of  masturbation,  both  in 
males  and  females.  In  some  instances  these  ideas  so  persist- 
ently annoy  and  distress  the  patients  as  to  give  rise  to  anoma- 
lous emotional  states  of  depression  which  in  women  some- 
times become  so  strong  that  they  demand  the  removal  of  the 
ovaries.  Many  of  the  cases  of  sexual  perversion  which  come 
under  observation  are  referable  to  these  impulses.  Although 
obsessions  of  genital  origin  are  among  the  most  common  forms, 
there  exists  a  great  variety  of  others.  For  example,  some 
patients  affirm  that  they  feel  compelled  to  lie  and  are  greatly 
worried  by  the  fear  that  they  will  be  unable  to  tell  the  truth. 
Occasionally  we  meet  with  instances  in  which  individuals  are 
seriously  disturbed  by  the  appearance  in  consciousness  of  an 
impulse  to  steal.  The  obsessions  which  give  rise  to  addiction 
to  drugs,  such  as  morphinomania  or  dipsomania,  often  entirely 
nullify  the  will  power  of  the  patient,  despite  the  fact  that  indi- 
viduals afflicted  in  this  way  may  do  their  very  best  and  resort 
to  a  variety  of  means  to  resist  the  obsession,  trying  hard  to 
divert  their  attention  or  to  extricate  themselves  from  all  situa- 
tions which  seem  to  favor  the  development  of  the  impulse. 
After  the  morphin  or  alcohol  has  been  taken,  in  all  probability 


PSYCHASTHENIC    STATES  531 

the  case  becomes  further  complicated  owing  to  the  toxic  action 
exerted  by  the  drugs  themselves. 

Reference  has  already  been  made  to  the  occurrence  of 
hallucinations  in  psychasthenic  states.  These  anomalous  sen- 
sations possess  many  of  the  characteristics  referred  to  in  de- 
scribing other  phenomena,  and  lack  the  stamp  of  reality  to  such 
an  extent  that  French  writers  believe  they  represent  an 
hallucinatory  mania  and  not  real  hallucinations.  The  hallu- 
cinations very  frequently  occur  as  visions.  In  patients  of  a 
low  intellectual  status  these  are  very  apt  to  be  associated  with 
current  superstitions  and  regarded  as  "  signs  from  Heaven" 
or  "  portents  of  the  future."  The  visual  forms  are  among 
the  most  common,  and  may  be  associated  with  sexual  ideas. 
For  example,  one  of  our  patients  used  to  affirm  that  she  saw 
a  naked  man  appear  before  her.  Auditory  hallucinations  are 
much  less  frequent,  although  at  times  patients  are  annoyed  by 
queer  sounds,  the  cropping  up  of  certain  tunes  in  their  mem- 
ories, the  endless  reiteration  becoming  a  source  of  intense 
worry. 

These  phenomena  are  supposed  to  have  a  symbolic  rela- 
tionship to  certain  objects.  At  times  they  seem  to  the  patient 
to  be  projected,  but  are  to  be  regarded  rather  as  the  reproduc- 
tion of  memory  pictures  characterized  by  incompleteness  and 
cloudiness  and  not  possessing  the  attributes,  such  as  the  form 
and  color,  of  a  real  object.  Belief  in  the  reality  of  these  phe- 
nomena is  never  marked  except  at  certain  critical  epochs  in 
their  development;  during  the  lucid  intervals  the  patient  is 
thoroughly  conscious  of  their  subjectivity.  The  mental  state 
which  may  develop  as  a  result  of  the  obsessive  ideas  and  hallu- 
cinations is  one  of  doubt,  the  so-called  delire  du  doute.  These 
sentiments  of  doubt  frequently  develop,  but  at  first  only  in 
reference  to  obscure  or  abstract  subjects.  Such  individuals  are 
particularly  worried  by  religious  questions,  and  the  fact  that 
they  can  not  carry  through  to  its  conclusion  a  train  of  thought 
is  to  them  most  distressing  and  serves  to  intensify  this  un- 
certainty. This  feeling  is  not,  as  some  writers  have  held,  a 
special  symptom,  but  is  rather  the  expression  of  the  intellect- 


532  PSYCHIATRY 

ual  state  generated  by  the  incompleteness  of  the  mental  opera- 
tions. 

It  would  appear,  however,  that  most  writers  have  spoken 
too  dogmatically  in  holding  that  the  integrity  of  consciousness 
is  preserved  during  the  crises,  although  it  is  an  undoubted  fact 
that  even  at  these  times  the  patients  may  struggle  to  free  them- 
selves from  the  thraldom  of  various  obsessions.  With  regard 
to  this  point  the  psychological  phenomena  need  to  be  studied 
more  in  detail  before  any  sweeping  generalizations  can  be  made. 
Disturbances  of  consciousness,  if  they  exist,  are  more  difficult 
of  demonstration  than  is  the  case  in  hysterical  subjects: 

The  defects  in  orientation,  that  occur  and  are  referable 
principally  to  slight  disturbances  in  the  sense  of  recognition, 
would  seem  to  lend  additional  color  to  the  view  that  conscious- 
ness is  not  as  intact  as  has  been  commonly  supposed.  Again, 
it  is  a  noteworthy  fact  that  some  of  these  individuals  seem  to 
have  a  double  personality.  Patients  may  affirm  that  they  feel 
as  if  they  were  in  another  world,  that  all  around  them  is 
strange  and  foreign. 

The  symptoms  already  referred  to  give  rise  to  secondary 
mental  disturbances  which  are  exhibited  in  anomalies  of  char- 
acter and  action.  Chief  among  these  is  the  vacillation  so  char- 
acteristic of  the  psychasthenic  when  forced  to  exert  himself. 
Such  individuals  feel  uncertain  and  are  perplexed  by  their  vari- 
ous doubts,  so  that  in  addition  to  the  mental  or  physical  fa- 
tigue, which  so  commonly  annoys  and  harasses  them,  they  are 
deterred  from  action  by  the  development  of  an  anomalous  men- 
tal state  or  are  enthralled  by  a  fixed  idea  relating  to  their  own 
physical  and  mental  incapacity.  Psychasthenics  never  form  a 
definite  resolution,  and  therefore  are  unable  to  act  spon- 
taneously; when  finally  driven  by  the  force  of  circumstances 
to  exert  themselves,  they  frequently  refer  to  what  they  do 
as  the  mere  expression  of  an  automaton  or  a  machine.  Con- 
scious that  their  volitional  movements  are  inhibited,  they 
affirm  that  they  are  dominated  by  a  strange  and  inexplicable 
power,  and  many  of  them  are  painfully  aware  of  the  incom- 
pleteness of  their  intellectual  acts,  are  harassed  by  their  ina- 


PSYCHASTHENIC    STATES 


533 


bility  to  direct  their  attention,  and  become  extremely  sensitive 
about  their  subjective  deficiency  of  perception.  The  emo- 
tional disturbances  blend  with  and  color  the  intellectual  and 
volitional  defects,  to  which  reference  has  already  been  made. 
Such  individuals  frequently  affirm  that  they  do  not  experi- 
ence the  ordinary  pleasures  of  life,  that  there  is  little  that 
arouses  in  them  a  sense  of  gratification  or  pleasure.  Fre- 
quently they  are  subject  to  attacks  of  mental  as  well  as  physical 
restlessness.  Not  only  is  this  common  during  their  waking 
hours,  but  patients  frequently  complain  that  their  sleep  is  dis- 
turbed and  that  they  cannot  rest  well  at  night.  This  restless- 
ness gives  rise  to  certain  indefinite  needs  which  the  patient 
feels  must  be  gratified.  Unquestionably  this  slight  motor  rest- 
lessness with  the  accompanying  apprehensiveness,  as  well  as  the 
obsessions,  plays  an  important  role  in  the  cases  of  individuals 
who  seek  for  relief  in  alcohol,  morphin,  or  cocain;  these  con- 
ditions are  also  favorable  for  the  development  of  erotic  im- 
pulses. As  an  antithetical  state  we  frequently  meet  with  an 
exaggerated  indolence,  the  patients  becoming  utterly  indifferent 
to  all  high  aims  and  ambitions.  Another  important  change 
which  is  frequently  noticed  is  the  tendency  shown  towards  the 
development  of  a  misanthropic  spirit,  which  will  often  explain 
the  so-called  social  abulia,  or  disinclination  to  go  into  society. 
Such  an  individual  is  inclined  to  become  more  or  less  isolated 
from  his  surroundings  and  lead  the  life  of  a  recluse.  On  the 
other  hand,  these  patients  may  show  an  excessive  need  of  the 
society  of  others  and  an  abnormal  craving  for  the  sympathy 
of  their  friends  and  relatives. 

Although  there  are  many  theories  regarding  the  cause  of 
these  psychasthenic  states,  there  is  practically  nothing  that  is 
definitely  known  regarding  their  development.  Some  ob- 
servers affirm  that  the  various  episodic  symptoms,  particularly 
the  obsessive  impulses,  are  really  secondary,  the  result  of  the 
reaction  of  the  impellent  idea  upon  the  emotional  life  of  the 
individual.  The  emotional  theories  are  referred  to  under  the 
section  dealing  with  obsessions.  The  hypothesis  of  greatest 
value  in  regard  to  the  genesis  of  the  disease  is  undoubtedly  that 


534 


PSYCHIATRY 


recently  proposed  by  Janet  and  Raymond,  in  which  the  appa- 
rent unity  of  the  phenomena  described  in  this  chapter  has  been 
pointed  out  and  the  chief  factor  in  the  pathogenesis  of  the 
mental  state  is  held  to  be  the  subjective  sense  of  incompleteness 
of  the  mental  activity.  The  lowering  of  the  psychic  and  ner- 
vous tension  is  assumed  to  be  the  fundamental  cause  under- 
lying all  these  conditions.  The  various  fluctuations  that  occur 
give  rise  to  the  differences  in  symptomatology.  The  observa- 
tions of  Janet  and  Raymond  have  added  greatly  to  our  clinical 
knowledge  of  this  disease.  Their  studies,  as  well  as  those  of 
Freud,  have  supplied  us  for  the  present  with  working  hypothe- 
ses which  greatly  facilitate  further  investigations. 

The  course  of  the  disorder  varies  greatly.  In  the  milder 
forms,  characterized  by  the  symptoms  of  nervous  exhaustion, 
the  condition  lasts  for  a  few  months,  while  in  the  severe  or 
more  protracted  types,  especially  in  those  in  which  the  heredi- 
tary predisposition  is  marked,  it  persists  with  more  or  less 
variation  during  the  greater  part  of  life.  The  latter  develop, 
as  a  rule,  in  individuals  in  whom  the  hereditary  factor  is  pres- 
ent, and  follow  some  exciting  cause,  such  as  injury,  a  severe 
attack  of  illness,  mental  shock,  etc.  Magnan  holds  that  these 
psychasthenic  states  are  always  to  be  regarded  as  stigmata  of 
degeneration.  The  various  manifestations  may  be  considered 
under  the  head  of  the  intermittent,  remittent,  and  continuous 
forms.  The  last  was  described  by  Roubinovitch  in  1893,  but 
can  not  be  sharply  distinguished  from  the  others. 

The  intermittent  form  is  characterized  by  the  various  epi- 
sodic symptoms  to  which  reference  has  already  been  made. 
They  generally  develop  whenever  some  exciting  cause,  such  as 
increased  mental  or  physical  fatigue,  intervenes,  or  follow  emo- 
tional disturbances.  Not  infrequently  long  remissions  may 
occur  in  the  forms  in  which  the  obsessions  and  phobias  have 
for  a  considerable  period  of  time  seemed  to  dominate  every 
thought,  while  in  other  cases  the  disturbed  and  more  lucid 
periods  alternate  rapidly.  Exacerbations  may  occur  daily, 
weekly,  or  at  much  longer  intervals.  The  temporary  improve- 
ment noted  in  these  cases  may  be  very  remarkable,  and  close 


PSYCHASTHENIC    STATES  535 

study  of  a  given  case  occasionally  renders  us  able  to  predict 
an  amelioration.  For  example,  Janet  calls  attention  to  the 
interesting  fact  that  the  psychasthenic  symptoms  frequently 
disappear  during  pregnancy. 

In  the  remittent  forms,  although  the  symptoms  already 
enumerated  show  a  marked  tendency  to  remit,  they  never  en- 
tirely disappear.  Quite  frequently  the  color  or  form  of  the 
obsession,  as  well  as  the  other  psychic  abnormalities,  may 
change,  but  the  emotional  state  of  the  patient  can  never  be  said 
to  be  quite  normal.  Even  when  the  episodic  symptoms  have 
practically  subsided  there  are  left  behind  a  certain  degree  of 
listlessness,  a  general  impairment  of  the  volitional  processes,  a 
lack  of  initiative,  and  a  lowering  of  the  whole  psychic  tone. 

Apart  from  the  physical  complications  to  which  reference 
has  been  made,  the  mental  symptoms  may  terminate  in  one  of 
several  ways :  ( 1 )  The  neurasthenic  state  may  become  chronic 
and  extend  over  a  long  period  of  years.  (2)  The  more  or  less 
stable  symptoms  of  chronic  nervous  exhaustion  may  be  compli- 
cated by  the  appearance  of  the  episodic  symptoms.  (3)  The 
hypochondriacal  and  other  obsessions  may  become  chronic  and 
systematized  so  that  we  have  conditions  resembling  some  of  the 
elementary  paranoiic  states.  In  certain  cases  the  symptoms 
may  entirely  disappear,  and  the  patient  is  said  to  be  cured. 
The  disease  may  be  slowly  progressive,  but  after  a  certain  point 
is  reached  the  symptoms  may  never  become  much  worse,  and 
remissions  may  frequently  occur.  In  rare  cases  the  obsessions 
and  impulses  become  exaggerated,  and  late  in  the  disease  other 
psychoses  complicate  the  clinical  picture. 

The  prognosis  in  the  episodic  forms  is  much  more  un- 
favorable than  in  the  other  types;  in  fact,  it  may  be  said  that 
a  cure  is  seldom,  if  ever,  effected.  There  are  competent  ob- 
servers who  maintain  that  the  forms  connecting  this  with  other 
forms  of  alienation  practically  never  occur,  but  the  general 
consensus  of  opinion  favors  the  view  that  transitional  states 
between  the  chronic  nervous  exhaustion  and  true  melancholia 
are  found  in  about  2  or  3  per  cent,  of  the  cases.  In  these 
we  have  a  neurasthenic  complex  of  symptoms  with  considerable 


536  PSYCHIATRY 

irritability,  and,  in  addition,  imperative  ideas  and  a  marked 
tendency  on  the  part  of  the  patient  to  try  and  establish  rela- 
tionships between  the  various  abnormal  sensations.13 

Attention  has  been  called  to  the  fact  that  some  cases,  par- 
ticularly those  in  which  the  abnormal  scrupulosity  (delire  du 
scruple)  is  well  marked,  may  end  in  states  of  exaltation  which 
are  closely  akin  to,  if  not  identical  with,  the  mystic  delirium 
common  in  hysterical  individuals. 

Various  other  forms  of  disturbances  in  the  field  of  con- 
sciousness with  and  without  more  definite  symptoms  of  alien- 
ation have  been  described  by  numerous  observers.  Cases  in 
which  marked  mental  confusion  and  deep  stupor  have  been 
reported  must  be  regarded  with  suspicion,  as  in  all  probability 
these  form  a  part  of  other  psychoses. 

Physical  Symptoms. — A  great  variety  of  objective 
symptoms  have  been  noted,  but  the  exact  relative  importance 
of  these  phenomena  can  not  be  accurately  estimated.  They  are, 
however,  so  frequent  and  of  such  intensity  as  to  warrant  the 
affirmation  that  these  psychasthenic  states  should  no  longer  be 
looked  upon  as  instances  of  purely  mental  disturbance,  in  the 
ordinary  sense  of  the  word.  The  mental  anomalies,  such  as 
the  obsessions,  states  of  apprehensiveness,  and  so  on,  are  nearly 
always  accompanied  by  a  variety  of  symptoms  which  seem  to 
indicate  the  existence  of  some  impairment  of  the  nervous  func- 
tions. In  the  more  chronic  cases  we  meet  with  various  forms 
of  neuralgias  and  other  painful  conditions.  The  attempt  has 
frequently  been  made  to  bring  these  anomalies  of  sensation  into 
relationship  with  the  supposed  disturbances  in  the  circulation. 
In  view  of  the  present  limitations  in  our  knowledge,  however, 
such  an  hypothesis  may  be  regarded  as  scarcely  plausible.  It 
is  interesting  to  note  in  passing  that  some  observers  have  at- 
tempted to  demonstrate  the  existence  in  neurasthenics  of  a 
definite  rise  of  temperature  associated  with  the  attacks  of 
severe    headache,    but    the    patients    usually    exaggerate    the 

13  Friedmann :     Ueber    Neurasthenische    Melancholic      Neurol.     Cen- 
tralbl.,  1903,  Nr.  2,  S.  1155. 


PSYCHASTHENIC    STATES  537 

trouble.  Insomnia  is  not  infrequent.  On  the  other  hand,  now 
and  again  we  meet  with  markedly  neurasthenic  individuals, 
more  especially  among  those  that  have  a  gouty  or  rheumatic 
diathesis,  who  never  seem  to  be  able  to  get  enough  sleep; 
who  are  victims  of  a  marked  degree  of  somnolence  and  who 
often  sleep  for  ten  or  twelve  hours  at  night,  with  occasional 
naps  during  the  day.  These  prolonged  periods  of  sleep,  how- 
ever, may  be  broken  by  dreams  of  a  disturbing  character, 
giving  rise  to  many  unpleasant  sensations.  In  nearly  all 
neurasthenic  or  psychasthenic  states,  all  the  reflexes,  more 
particularly  the  superficial,  are  apt  to  be  increased  in  in- 
tensity. Dermatographia  is  commonly  a  prominent  symp- 
tom. Cases  are  reported  in  which  the  ankle  and  patellar  clonus 
have  been  elicited,  but  these  should  be  viewed  with  suspicion, 
and  the  possible  existence  of  a  cord  lesion  must  always  be 
remembered.  The  pupillary  reflexes  are,  as  a  rule,  very  active, 
at  times  a  marked  hippus  being  present.  In  the  states  of 
chronic  nervous  exhaustion  the  pupils  are  apt  to  be  quite  widely 
dilated.  The  nutrition  of  these  patients  generally  suffers  con- 
siderably. A  great  many  of  them  are  poorly  nourished  and 
more  or  less  anaemic.  Nevertheless,  others  show  an  excess  of 
adipose  tissue  and  may  become  exceedingly  stout.  As  a  rule, 
the  haemoglobin  is  somewhat  reduced  in  quantity.  The  appe- 
tite, in  states  of  hysteria,  is  often  very  capricious.  At  times 
these  individuals  eat  practically  nothing,  while  again  they  may 
exhibit  an  abnormal  craving  for  food  and  remarkable  idiosyn- 
crasies of  taste.  Some  observers  maintain  that  the  digestive 
disturbances  of  the  neurasthenic  are  dependent  upon  deficient 
secretion  of  the  gastric  glands,  and  still  more  often  motor 
insufficiency  of  the  gastric  muscle,  as  a  consequence  of  which 
the  contents  of  the  stomach  are  not  discharged  within  the  nor- 
mal time  and  gastric  fermentation  and  certain  forms  of  auto- 
intoxication result.  Undoubtedly  many  cases  of  nervous  dys- 
pepsia are  quite  amenable  to  suggestion,  and  the  emotional 
state  of  the  patient  at  the  time  that  the  food  is  taken  is  a  very 
important  factor  in  digestion.  Moreover,  with  the  gastric  dis- 
turbances are  associated  others  of  intestinal  origin,  the  most 


538  PSYCHIATRY 

important  being  diarrhoea  and  constipation,  which  often  alter- 
nate. 

The  nutritional  defects  become  more  evident  in  the  cases 
in  which  there  is  a  lithsemic  or  a  gouty  diathesis.  The  urine 
of  these  patients,  however,  is  not  at  all  characteristic,  and  anal- 
yses furnish  no  clues  which  would  serve  to  explain  the  ac- 
companying mental  conditions.  Even  the  observations  regard- 
ing the  general  diminution  of  the  urea  and  the  increase  of 
uric  and  phosphoric  acids  are  questionable.  The  same  may 
be  said  regarding  the  presence  of  indican  and  skatol. 

Abnormalities  in  the  circulation  in  neurasthenics  are  very 
common.  Associated  with  the  vasomotor  disturbances,  to 
which  reference  has  already  been  made,  we  not  infrequently 
find  a  tachycardia.  Bradycardia  is  sometimes  noted,  but  when 
this  sign  is  marked  and  persistent,  it  can  usually  be  accounted 
for  by  the  existence  of  some  complication.  The  pulse  is  often 
irregular,  both  in  force  and  rhythm.  Some  observers,  par- 
ticularly De  Fleury,  affirm  that  in  a  large  number  of  neuras- 
thenics there  is  a  hypertension,  and  look  upon  the  symptoms 
of  the  disorder  as  evidences  of  an  autointoxication. 

The  changes  in  the  circulation  occurring  during  the  epi- 
sodic symptoms  have  been  spoken  of  in  the  introductory  sec- 
tion. There  are  no  marked  abnormalities  affecting  the  respi- 
ration excepting  during  the  periods  of  excitement  or  anxiety. 
Certain  observers  have  called  attention  to  the  frequency  of 
cutaneous  lesions  in  cases  of  psychasthenia,  more  particularly 
various  forms  of  eczema,  and  not  uncommonly  seborrhcea,  ab- 
sence of  tears,  and  rhinorrhcea.  In  women  disturbances  of  the 
menstrual  functions  are  common. 

As  has  already  been  pointed  out,  there  is  no  disturbance 
in  the  muscular  power  for  sudden  spasmodic  effort,  but  the 
symptoms  of  fatigue  appear  very  early,  and  the  sudden  fall 
in  the  curve  representing  the  dynamic  power  of  the  muscle  is 
nearly  always  a  constant  symptom. 

Differential  Diagnosis. — The  recognition  of  neuras- 
thenia is  frequently  beset  with  many  difficulties.  Neurasthenic 
states  are  encountered  in  the  early  stages  of  the  more  acute 


PSYCHASTHENIC    STATES 


539 


psychoses,  as  well  as  of  dementia  prsecox,  dementia  paralytica, 
hysteria,  and  manic-depressive  insanity.  In  hysteria,  as  a  rule, 
the  occurrence  of  the  typical  attacks,  the  motor  spasms,  the 
paralyses,  and  the  fairly  characteristic  disturbances  of  sensa- 
tion are  differential  points.  Again,  the  hysterical  states  are 
more  apt  to  be  characterized  by  a  number  of  definite  symptoms 
and  a  more  or  less  complete  obliteration  of  certain  functions 
with  an  exaggeration  of  others.  In  psychasthenia  there  are 
no  complete  lacunse  in  sensation,  memory,  or  in  the  motor 
functions.  It  is  this  characteristic  of  the  hysterical  manifes- 
tations which  stamps  the  phenomena  as  automatic,  and  gives 
to  the  motor  disturbances,  impulsions,  and  other  motor  symp- 
toms a  regularity  in  rhythm,  which  is  not  noted  in  other  dis- 
eases (Janet).  The  cases  in  which  obsessional  ideas  and 
impulses  are  present  may  frequently  give  rise  to  considerable 
difficulty  in  differentiation,  and  the  absence  of  true  hysterical 
stigmata  is  frequently  the  only  means  of  arriving  at  a  positive 
diagnosis. 

Not  uncommonly  the  initial  stages  of  dementia  prcecox 
are  characterized  by  the  appearance  of  psychasthenic  symptoms 
which  may  last  for  a  considerable  period  of  time  before  the 
development  of  the  stereotypies,  mannerisms,  and  explosive- 
like impulses.  Cases  strongly  suggestive  of  neurasthenia,  but 
developing  in  young  persons,  particularly  girls,  at  or  about  the 
time  of  puberty,  and  accompanied  by  very  severe  attacks  of 
migraine,  with  a  tendency  at  times  to  a  mild  degree  of  emo- 
tional apathy,  should  at  once  give  rise  to  suspicions  regarding 
the  existence  of  dementia  prsecox.  The  psychasthenic  states, 
in  which  the  impulses  are  prominent,  are  usually  characterized 
by  a  certain  degree  of  emotional  instability,  but  the  idea  in 
consciousness  and  the  objective  expressions  of  the  emotion  are 
likely  to  correspond.  The  dissociation  of  these  two  factors,  as 
has  already  been  pointed  out  elsewhere,  is  characteristic  of 
dementia.  Furthermore,  in  psychasthenia,  the  condition  is 
more  stable  and  psychic  hallucinations  are  absent. 

Not  infrequently,  for  a  short  period  of  time,  in  the  very 
early  stages  of  an  attack   of  manic-depressive  insanity,   the 


540  PSYCHIATRY 

symptoms  may  be  suggestive  of  psychasthenic  states.  The  dif- 
ferentiation, however,  should  hardly  prove  to  be  very  difficult 
if  the  patient  is  kept  under  close  observation  for  several  days, 
except  in  the  very  mild  cases  and  during  the  period  of  de- 
pression. But  even  here  it  will  be  helpful  to  remember  that 
the  neurasthenic  usually  retains  a  much  clearer  insight  into 
his  own  condition  and  shows  no  evidence  of  psychomotor  re- 
tardation. The  physical  state  in  psychasthenics  remains  prac- 
tically unchanged,  whereas  in  the  manic-depressive  conditions 
the  patient  is  apt  to  show  a  more  or  less  sudden  loss  of  weight 
and  not  infrequently  considerable  disturbances  in  the  gastro- 
intestinal tract. 

It  often  happens  that  the  initial  stages  of  paresis  can  be 
distinguished  from  psychasthenic  states  only  with  the  greatest 
difficulty.  Here  a  complete  history  of  the  patient  is  of  the 
greatest  possible  value.  In  individuals  who  prior  to  middle 
life  have  never  experienced  any  nervous  breakdowns  and  who 
have  enjoyed  good  health,  the  appearance  of  a  psychasthenic 
condition,  especially  if  there  does  not  seem  to  be  any  immediate 
cause  for  it  and  if  it  be  protracted,  should  at  once  make  us  sus- 
pect a  developing  dementia  paralytica.  This  suspicion  becomes 
stronger  if,  in  addition  to  the  symptoms  of  chronic  nervous 
exhaustion,  signs  of  ethical  and  social  defects  in  character  be- 
come at  all  prominent.  The  appearance  of  temporary  paralyses 
of  the  eye-muscles,  of  incoordination  in  the  facial  movements, 
of  some  difficulty  in  speech,  or  a  slight  impairment  of  the  light 
reflexes  are  frequently  sufficient  grounds  for  leading  the  physi- 
cian to  believe  that  he  is  dealing  with  a  case  of  paresis,  and 
not  one  of  psychasthenia.  The  same  is  true  in  regard  to  the 
occurrence  of  attacks  of  vertigo  associated  with  temporary 
aphasia  and  an  increase  in  the  difficulty  of  speech.  In  psychas- 
thenia the  clinical  memory  tests  are  much  less  apt  to  reveal 
the  existence  of  positive  defects  than  is  the  case  in  dementia 
paralytica. 

Disturbances  in  the  emotional  life  of  the  individual  in 
psychasthenia  are  much  more  apt  to  be  the  result  of  excessive 
reaction  to  stimuli   from  without  or  of  mere  transitory  im- 


PSYCHASTHENIC    STATES  541 

pulses  than  of  actual  defects  in  judgment,  as  is  so  frequently 
the  case  in  dementia  paralytica.  Again,  insane  ideas  are  much 
more  characteristic  of  the  latter  than  of  the  former  condition. 

In  the  early  stages  of  various  acute  psychoses  we  not  infre- 
quently meet  with  symptoms  which  also  belong  to  chronic  ner- 
vous exhaustion  or  the  typical  psychasthenic  states,  but  in  the 
former  these  usually  give  way  in  a  few  days  to  the  more  pro- 
nounced manifestations  of  alienation. 

Etiology. — The  inciting  causes  of  the  majority  of  cases 
of  neurasthenia  are  too  numerous  to  receive  mention  here.  In  re- 
gard to  the  factors  that  primarily  give  rise  to  the  episodic  symp- 
toms little  definite  can  be  said.  Loewenfeld  cites  the  following 
causes  as  provocative  of  states  of  apprehensiveness,  and  these 
same  agents  doubtless  play  an  important  part  in  the  genesis 
of  the  episodic  symptoms  :  ( 1 )  A  predisposition,  the  result  of 
abnormal  heredity,  which  serves  to  accentuate  the  effect  of 
inciting  agencies.  (2)  Essential  or  more  immediately  opera- 
tive causes,  either  somatic  or  psychical.  Among  the  former  are 
classed  the  sexual,  and  among  the  latter  the  emotional  dis- 
turbances. (3)  Accessory  causes  that  may  temporarily  inter- 
fere with  the  functions  of  the  central  nervous  system. 

Treatment. — In  the  treatment  of  neurasthenia  a  great 
deal  of  good  may  be  accomplished  by  the  complete  or  modified 
rest-cure  (see  chapter  on  Treatment),  but  in  the  episodic  forms 
an  amelioration  of  the  symptoms  is  practically  all  that  can  be 
hoped  for.  As  has  already  been  pointed  out,  the  hereditary 
factor  is  so  dominant  that  prophylaxis  becomes  a  question  of 
vital  importance.  Unfortunately,  psychasthenics  may  be  the 
product,  not  of  one,  but  of  several  generations;  and  although 
in  an  advanced  state  of  society  it  might  be  possible  to  eliminate 
many  of  the  hereditarily  predisposed  individuals  by  requiring 
a  medical  certificate  permitting  parties  to  marry,  this  desider- 
atum could  not  be  attained  until  the  procedure  had  been  in 
force  for  many  years.  The  danger  of  consanguineous  mar- 
riages has  been  frequently  emphasized,  as  the  children  of  such 
parents  are  particularly  apt  to  develop  marked  psychasthenic 
states,  particularly  if  there  have  been  anomalous  traits  of  char- 


542  PSYCHIATRY 

acter  in  the  family.  Another  important  danger  noted  by- 
numerous  observers  is  the  fact  that  marriage,  not  only  between 
members  of  an  undesirable  family,  but  between  the  members 
of  families  who  have  for  several  generations  been  devoted  to 
the  same  pursuits,  is  fraught  with  danger.  Thus,  in  the  case 
of  marriages  of  individuals  belonging  to  highly  intellectual 
circles,  particularly  the  university  sets,  the  children  seem  to 
exhibit  an  exaggeration  of  mental  idiosyncrasies  and  traits 
similar  to  those  possessed  by  the  parents.  This  fact  provides 
one  of  the  strongest  arguments  against  the  excessive  education 
of  women,  particularly  in  this  country.  There  can  be  little 
question  that  when  the  women  have  the  same  intellectual  aims 
and  ambitions  as  the  men  the  tendency  towards  the  develop- 
ment of  peculiarities  of  character,  anomalies  of  emotion,  and 
mental  tics  is  strongly  accentuated  in  the  children.  As  has 
frequently  been  noted,  there  is  a  remarkable  tendency  shown 
in  the  families  in  whom  gout  is  present  to  the  development  of 
psychasthenic  states  in  the  children.  Prophylaxis  in  these  cases 
would  necessitate  more  simple  nourishment  on  the  part  of  the 
parents,  the  giving  up  of  alcohol  in  any  form,  and  a  more 
rational  out-door  life.  In  families  in  which  the  parents  are 
devoted  to  purely  intellectual  pursuits  it  is  important  that  the 
children  should  be  removed  as  far  as  possible  from  the  ten- 
dency to  what  the  French  call  "  mental  rumination."  From 
an  early  age  they  should  be  accustomed  to  interest  themselves 
in  manual  labor,  in  out-door  sports,  but  not  to  excess;  they 
should  never  be  forced  at  school,  nor  should  any  mental  exer- 
cises be  encouraged  if  the  child  shows  a  tendency  to  become 
isolated  from  its  companions  or  to  indulge  in  flights  of  fancy 
or  speculation.  Everything  should  be  done  to  encourage  in 
the  child  a  healthy  social  character.  On  the  appearance  of 
abnormal  symptoms — excessive  embarrassment,  precocious - 
ness,  or  a  tendency  to  hold  aloof  from  companions — the  child 
should  be  removed  from  its  surroundings,  and,  if  possible, 
sent  to  the  country  or  to  some  boarding-school  where  the 
mental  regime  is  less  strenuous  and  every  opportunity  is  given 
for  the  cultivation  of  a  healthy  nervous  system.     Above  all 


PSYCHASTHENIC    STATES  543 

things,  the  children  should  not  be  taught  to  interpret  pleasure 
merely  as  being  the  absence  of  pain  or  discomfort.  Particu- 
larly harmful  are  all  the  tendencies  which  encourage  in  chil- 
dren introspection,  and  equally  undesirable  are  the  various 
forms  of  so-called  religious  instruction  which  are  frequently 
inflicted  upon  young  people.  Coming,  as  they  do,  at  a  time 
when  there  is  need  of  self-restraint  and  the  exercise  of  the  nor- 
mal reasoning  powers,  they  tend  to  substitute  the  play  of  the 
emotions  and  to  inculcate  the  dangerous  principle  of  being 
guided  by  impulse  and  by  what  the  individual  without  reflection 
believes  to  be  the  proper  course. 


CHAPTER    XIX 

PSYCHOSES  ASSOCIATED   WITH   ORGANIC  DISEASE  OF  THE   CEN- 
TRAL NERVOUS  SYSTEM.1 

Disturbances  in  the  mental  functions  associated  with 
organic  lesions  in  the  central  nervous  system  are  not  very  un- 
common, prominent  among  them  being  the  psychical  anomalies 
described  in  connection  with  the  following  disorders : 

Multiple  Sclerosis. — With  the  earlier  stages  of  this  dis- 
ease are  sometimes  associated  a  variety  of  neurasthenic  symp- 
toms which  give  rise  to  difficulties  in  diagnosis.  At  times  these 
manifestations  of  fatigue,  both  mental  and  physical,  are  present 
for  a  considerable  period  of  time  before  the  tremor,  disturb- 
ances of  speech,  or  other  more  or  less  distinctive  signs  make 
their  appearance.  Occasionally  marked  disturbances  in  the 
affective  life  of  the  individual  are  noted  and  the  patient  is 
subject  to  ungovernable  outbursts  of  temper,  which  sweep  over 
him  with  little  provocation  and  which,  after  they  have  passed, 
may  occasion  a  genuine  sense  of  remorse.  As  a  rule,  the  pa- 
tient retains  an  insight  into  his  own  condition ;  he  appreciates 
that  he  is  ill  and  that  the  nervous  and  mental  disturbances  are 
the  result  of  the  disordered  functioning  of  his  nervous  system. 
In  some  instances  these  symptoms  are  slowly  progressive,  in 
others  they  are  remittent,  and  the  patient  may  show  a  tem- 
porary improvement  sufficiently  marked  to  excite  general  com- 
ment among  his  friends.  The  mental  disturbances  and  the 
physical  signs  are  not  proportional,  sometimes  the  former,  in 
other  cases  the  latter,  predominating,  and  they  seem  to  bear  no 
definite  relationship  to  each  other.  As  a  rule,  in  the  early 
stages,  when  the  neurasthenic  symptoms  are  marked  and  when 

1  Hunt,  J.  Ramsay :  Multiple  Sclerosis  with  Dementia :  A  Contribu- 
tion to  the  Combination  Form  of  Multiple  Sclerosis  and  Dementia  Par- 
alytica. Am.  Journ.  of  Med.  Sci.,  December,  1003.  Dupre,  E. :  Psycho- 
pathies organiques.     In  Ballet's  Traite  de  Pathologie  Mentale,  Paris,  1903. 

544 


MULTIPLE    SCLEROSIS 


545 


the  insight  is  well  retained,  the  emotional  tone  is  one  of  depres- 
sion, but  later  on  this  may  be  lost,  and  the  patient,  becoming 
more  or  less  unconscious  of  his  abnormal  state,  shows  evi- 
dences of  some  slight  euphoria,  a  condition  that  is  characterized 
by  an  increased  sense  of  well-being  and  a  certain  boastfulness 
which  in  a  measure  are  suggestive  of  dementia  paralytica.2 
In  addition  to  the  defects  already  noted,  impairment  of  asso- 
ciative memory  is  frequently  a  prominent  symptom,  and  this 
may  give  rise  to  slight  disturbances  in  orientation,  the  latter, 
as  a  rule,  being  less  pronounced  than  in  general  paresis.  The 
mental  symptoms,  as  has  already  been  pointed  out,  generally 
develop  more  or  less  irregularly,  although  in  some  cases  con- 
siderable impairment  of  the  various  faculties  is  noted.  As  a 
rule,  certain  functions  remain  unaffected,  and  in  this  respect 
the  mental  condition  in  multiple  sclerosis  differs  essentially 
from  that  observed  in  dementia  paralytica,  where  practically 
there  is  an  involvement  of  all  the  psychic  functions.  The 
multiplicity  of  the  symptoms  which  may  occur  in  the  sclerotic 
process  and  the  frequent  difficulty  that  is  experienced  in  estab- 
lishing a  positive  diagnosis  have  been  particularly  emphasized 
by  a  number  of  investigators.3 

The  pathological  changes  in  the  central  nervous  system 
can  not  be  discussed  in  detail  here.  Although  the  sclerotic  areas 
are  occasionally  noted  in  the  cerebral  cortex,  they  are  much 
more  common  in  the  white  matter  as  well  as  in  the  basal  gan- 
glia and  cerebellum.4  When,  as  sometimes  happens,  sclerotic 
changes  are  present  in  the  corpus  callosum,  many  authorities 
hold  that  they  are  of  great  significance  in  the  pathogenesis 
of  the  mental  symptoms.  Nevertheless,  other  factors,  such  as 
autointoxication,  must  be  considered,  and  it  is  improbable  that 
these  areas  are  the  sole  cause  of  the  dementia,  since  the  study 

3  Starr,  M.  Allen :  Organic  Nervous  Diseases.  New  York  and  Phila- 
delphia, 1903,  p.  701. 

*  Philippe,  CI.,  et  Castan :  Memoire  depose  pour  le  prix  civrieux  a 
l'Academie  de  Medecine.  Daunenberger :  Inaug.  Dissertation,  Giessen, 
1901. 

*  Philippe  and  Jones :  Etude  anatomo-pathologique  de  l'ecorce  cere- 
brale  dans  la  sclerose  en  plaques.     Soc.  d.  Neurol.,  1899. 

35 


546  PSYCHIATRY 

of  the  cellular  elements  in  these  cases  has  brought  to  light  a 
more  or  less  general  involvement  of  all  the  cortical  cells,  in 
some  instances  amounting  to  a  pigmented  atrophy. 

Amyotrophic  Lateral  Sclerosis. — Mental  disturbances 
in  this  disease  have  been  reported  by  a  number  of  writers. 
Mott,  Spiller,5  and  other  investigators  have  called  attention  to 
the  fact  that  in  these  cases  there  may  be  demonstrable  changes 
in  the  cerebral  cortex.  The  mental  symptoms  are  not  in  any 
sense  specific,  and,  as  a  rule,  develop  after  those  depending 
upon  the  lesions  have  become  so  pronounced  that  the  former 
may  be  regarded  as  secondary  in  importance. 

Apoplexy. — Mental  anomalies  may  either  precede  or 
follow  a  cerebral  hemorrhage.  When  they  occur  as  pro- 
droma  they  often  consist  merely  in  nervousness,  considerable 
emotional  irritability,  and  varied  disturbances  in  associative 
memory.  Sometimes  the  patients  become  unusually  irritable; 
they  are  subject  to  outbursts  of  temper  or  may  be  markedly 
hysterical,  laughing  and  crying  apparently  without  any  provo- 
cation. Following  the  attack,  various  manifestations  are  noted. 
The  extent  and  severity  of  these  are  not  at  all  proportional  to 
the  physical  symptoms,  nor,  with  a  few  exceptions,  do  they 
seem  to  be  influenced  by  the  location  of  the  lesion.  Starr's  6 
experience  agrees  with  that  of  Seguin  and  Brissaud,  that  when 
the  lesion  is  in  the  right  temporal  lobe  the  loss  of  emotional 
control  seems  to  be  more  marked  than  when  located  elsewhere. 
The  intensity  of  the  symptoms  varies  greatly,  from  a  mild 
degree  of  apathy  to  attacks  of  maniacal  excitement  with  im- 
pulsive acts  of  various  kinds.  Then,  as  is  often  the  case,  the 
changes  are  progressive;  the  mental  enfeeblement  becomes 
more  and  more  pronounced  until  a  profound  dementia  super- 
venes. But  it  must  be  remembered  that  the  mere  local  lesion 
is  not  in  any  sense  the  immediate  cause  of  this  general  mental 
impairment,  but  unquestionably  other  causes,  such  as  arterial 


5  A  case  of  amyotrophic  lateral  sclerosis.      A  contribution  from  the 
Pepper  Laboratory  of  Clinical  Medicine.    Philadelphia,  1900. 
8  Op.  cit. 


MENINGITIS 


547 


changes  or  areas  of  softening,  are  subsidiary  factors.  The  at- 
tacks characterized  by  hysterical  symptoms  are  not  at  all  in- 
frequent ;  the  patients  burst  into  laughter  or  tears  without  any 
or  on  very  slight  provocation,  and  are  unable  to  control  their 
emotions.  Associative  memory  is  nearly  always  impaired,  the 
defect  being  sometimes  general  and  at  other  times  isolated, 
certain  functions  being  well  preserved  while  others  are  more 
or  less  completely  lost.  The  insight  retained  by  the  patient 
into  his  own  condition  varies  greatly  and  depends  upon  a  num- 
ber of  circumstances.  In  some  instances  the  individual  appre- 
ciates to  a  remarkable  extent  the  nature  of  his  trouble,  in  others 
not  at  all.  The  character  of  the  dementia  that  frequently  de- 
velops in  these  cases  can  not  be  distinguished  from  that  occur- 
ring in  the  arteriosclerotic  or  in  the  senile  forms  of  alienation. 

The  relation  of  tabes  to  dementia  paralytica  and  the  occur- 
rence of  mental  symptoms  during  the  course  of  the  former  dis- 
ease are  subjects  that  are  discussed  in  Chapter  XV. 

Meningitis. — Mental  symptoms  are  frequently  observed 
in  cases  of  meningitis.  In  the  first  place,  there  may  be  merely 
the  clouding  of  the  consciousness  or  the  disturbances  in  organic 
sensibility  which  are  common  in  any  febrile  disease.  In  other 
cases,  particularly  in  epidemic  cerebrospinal  meningitis,  as  well 
as  in  the  septic,  tuberculous,  and  syphilitic  forms,  there  may 
be  all  grades  of  deliria  varying  from  the  mildest  type  already 
referred  to  to  the  most  pronounced  maniacal  excitement  in 
which  the  patient  is  kept  in  bed  only  with  the  greatest  diffi- 
culty. In  these  severe  cases,  in  addition  to  the  clouding  of 
consciousness,  fallacious  sense  perceptions,  which  vary  greatly 
in  character,  are  quite  common.  Sometimes  the  visual  forms 
predominate ;  at  other  times  they  are  associated  with  auditory 
and  somatic  hallucinations.  The  degree  of  fever  and  the  men- 
tal aberration  are  by  no  means  always  parallel.  Even  with  a 
relatively  low  temperature  certain  patients  show  a  marked  ten- 
dency to  become  wildly  delirious,  whereas  in  other  cases,  despite 
a  marked  degree  of  hyperpyrexia,  the  mental  faculties  are  re- 
markably well  preserved.  In  some  instances  early  in  the  dis- 
ease there  are  evidences  of  well-defined  local  lesions,  whereas 


548  PSYCHIATRY 

in  others  the  infection  seems  to  be  of  a  more  general  type  and 
the  mental  symptoms  predominate.  Clinically,  we  have  to 
distinguish  between  the  meningitis  which  occurs  as  a  primary 
uncomplicated  disease  and  those  forms  which  complicate  other 
disorders,  such  as  dementia  paralytica,  senile  psychoses,  alco- 
holism, etc. 

Brain  Abscess. — Localized  collections  of  pus  in  the  brain, 
in  addition  to  the  physical  signs,  are  not  infrequently  attended 
by  a  variety  of  mental  symptoms,  none  of  which,  however,  are 
in  any  sense  to  be  regarded  as  specifically  characteristic.  In 
some  instances  there  is  merely  a  mild  degree  of  motor  restless- 
ness or  the  patient  becomes  excessively  irritable,  while  in  other 
cases  there  are  varying  degrees  of  apathy  or  stupor.  Cases 
have  been  recorded  in  which  the  abscess  was  attended  by  symp- 
toms of  marked  depression  or  by  degrees  of  motor  restlessness 
and  exhilaration  which  simulated  a  true  mania.  In  the  in- 
stances in  which  the  history  of  infection  is  obtained  and  where 
there  are  localizing  symptoms  as  well  as  febrile  disturbances 
the  diagnosis  is  not  difficult,  but  in  the  more  protracted  cases, 
where  the  abscess  becomes  encapsulated  and  the  mental  symp- 
toms are  the  most  dominant  clinical  feature,  a  diagnosis  fre- 
quently can  only  be  made  with  the  greatest  difficulty,  and  in 
some  instances  the  real  cause  can  not  be  recognized  without  an 
autopsy. 

The  mental  disturbances  associated  with  thrombi  or  em- 
boli in  the  cerebral  vessels  do  not,  as  a  rule,  depend  upon  the 
local  disturbances,  but  are  referable  to  a  number  of  factors 
that  cannot  be  appropriately  discussed  here. 

Brain  Tumors.7 — Not  all  tumors  of  the  brain  cause 
symptoms  of  a  sufficiently  pronounced  character  to  render  their 
recognition  easy.  As  can  readily  be  gathered  from  the  litera- 
ture, even  large  tumors  have  been  found  at  autopsy  in  the  cen- 
tral nervous  system  which  during  life  had  caused  no  note- 
worthy manifestations.     On  the  other  hand,  relatively  small 

7  Schuster,  Paul :     Psychische  Storungen  bei  Hirntumoren.     Stuttgart, 
1902. 


BRAIN    TUMORS  549 

neoplasms  may  give  rise  to  marked  local  disturbances  as  well 
as  to  a  more  or  less  general  impairment  of  all  the  mental  fac- 
ulties. In  the  face  of  these  apparently  contradictory  facts,  as 
well  as  for  other  reasons,  it  is  often  impossible  to  determine 
how  far  the  symptoms  of  alienation  are  directly  due  to  the 
presence  of  a  tumor,  and  in  the  majority  of  cases  the  mental 
defects  must  doubtless  be  regarded  as  secondary  manifesta- 
tions. It  would  be  interesting  and  of  great  practical  impor- 
tance to  determine  in  what  percentage  of  cases  a  well-marked 
alienation  develops  directly  as  the  result  of  a  neoplasm  in  indi- 
viduals who  are  not  hereditarily  predisposed  towards  aliena- 
tion. Thus  in  73  patients  Schuster  affirms  that  in  only  10 
per  cent,  were  there  evidences  of  a  marked  predisposition 
shown  by  the  occurrence  of  mental  abnormalities — particularly 
nervousness  and  a  tendency  to  alcoholism — prior  to  the  devel- 
opment of  the  tumor.  As  has  already  been  pointed  out,  the 
growth  of  the  tumor  is  not  so  uncommonly  accompanied  by 
a  marked  degree  of  mental  aberration.  In  some  cases  this 
amounts  merely  to  disturbances  in  the  affective  life.  The  pa- 
tients become  easily  fatigued  and  display  a  considerable  degree 
of  distractibility.  They  are  easily  irritated  and  may  be  sub- 
ject to  violent  outbursts  of  temper.  In  younger  individuals, 
on  the  other  hand,  apathy,  distractibility,  and  in  some  instances 
lethargy  and  somnolence  are  more  likely  to  occur.  Outbreaks 
of  delirium  are  sometimes  noted,  but  when  these  occur  the 
possibility  that  the  tumor  is  complicated  by  the  development  of 
some  independent  psychosis  should  not  be  lost  sight  of.  Schus- 
ter and  others  have  shown  that  the  tumor  may  simply  be  a 
factor  of  secondary  importance  when  it  precedes  an  attack  of 
manic-depressive  insanity,  dementia  prsecox,  amentia,  etc. 
Sometimes,  however,  it  may  in  a  way  precipitate  the  alienation 
by  lowering  the  mental  and  physical  resistance  of  the  patient, 
and  because  its  presence  may  cause  an  actual  circulation  in 
the  blood  of  toxins  which  may  give  rise  to  certain  delirious 
states.8     As  a  rule,  except  in  the  case  of  the  frontal  lobe  tu- 

8  Wollenburg :    Centralbl.  f.  Nervenheilk.  u.  Psych.,  1903,  Bd.  xxvi,  Nr. 
156. 


55o 


PSYCHIATRY 


Predis- 

Heredity 

position 

Alcoholism 

5 

4 

8 

3 

5 

•  • 

2 

2 

5 

I 

5 

I 

-2 

4 

2 

2 

2 

3 

2 

3 

3 

3 

2 

i 

I 

7 

2 

5 

mors,  the  location  of  the  neoplasm  does  not  give  a  specific 
stamp  to  the  mental  symptoms.  The  great  variety  of  recorded 
mental  disturbances  observed  in  cases  of  brain  tumor  will 
appear  from  the  following  table  from  Schuster's  work : 

Total 

Excitement 95 

Melancholia 57 

Delirium  and  confusion.  .  52 

Dementia  paralytica 29 

An  abnormal  tendency  to 

jest 23 

Paranoiic   states 19 

Neurasthenic   states 15 

Mania 13 

Moral   insanity 7 

Circular  insanity 5 

Simple  mental  weakness..  423 

Mental  Disturbances  Associated  with  Arterio- 
sclerosis.9— Not  only  have  recent  investigations  added  ma- 
terially to  our  knowledge  regarding  the  pathological  changes 
taking  place  in  the  central  nervous  system  as  the  result  of 
vascular  sclerosis,  but  considerable  advance  has  also  been  made 
in  establishing  a  closer  relationship  between  some  of  the  lesions 
and  the  symptoms.  For  this  reason  it  has  been  considered 
advisable  to  change  the  order  hitherto  followed  in  the  descrip- 
tion of  other  diseases,  so  as  to  emphasize  as  much  as  possible 
the  importance  of  the  alterations  in  the  central  nervous  system 
as  the  determining  factor  in  the  development  of  the  clinical 
picture. 

Meyer  has  called  attention  to  the  fact  that  the  nervous 
system  may  suffer  in  three  ways  as  the  result  of  arteriosclero- 
sis:    ( 1 )  there  is  a  reduction  or  marked  change  of  metabolism 


9K6ppen:  Arch.  f.  Psych.,  Bd.  xx,  S.  891.  Binswanger:  Berl.  klin. 
Wchnschr.,  1894.  Alzheimer:  Allg.  Ztschr.  f.  Psych.,  1895,  Bd.  li,  S.  809. 
Monatsschr.  f.  Psych,  u.  Neurol.,  Bd.  iii.  Centralbl.  f.  Nervenheilk.  u. 
Psych.,  xxv.  Jahrg.,  Nr.  149,  Juni  15,  1902,  S.  399.  Noison  et  Coyne, 
Union  med.,  1869.  Meyer,  Adolf :  Albany  Medical  Annals,  vol.  xxiv, 
No.  3,  1903. 


ARTERIOSCLEROSIS  55 1 

due  to  the  arteriosclerotic  disease  in  one  or  more  organs;  (2) 
the  changes  in  the  nervous  system  are  directly  the  result  of 
disturbances  in  the  vascular  mechanism;  or  (3)  there  may  be 
a  lowered  metabolism  due  to  a  state  of  exhaustion  caused  by 
the  action  of  toxic  substances. 

The  forms  of  alienation  associated  with  this  disease  are 
more  common  after  the  fiftieth  year  of  life,  but  they  are  not 
infrequently  present  at  the  fortieth  year  or  even  earlier. 

An  example  of  mental  disturbance  with  arteriosclerosis, 
as  it  is  sometimes  seen  in  young  people,  is  given  in  the  follow- 
ing abstract  from  the  history  of  a  case,  for  which  I  am  indebted 
to  Dr.  Cary  B.  Gamble,  Jr. : 

Patient,  white;    male;    aged  22. 

Family  history  good,  except  that  the  patient's  father  died  of  tuber- 
culosis. 

Personal  History. — Denies  lues  and  has  no  scar  or  enlarged  glands. 
Five  years  ago  the  patient  had  a  moderately  severe  attack  of  typhoid  fever, 
from  which  he  convalesced  rather  slowly.  For  the  past  two  years  he 
has  been  unable  to  fasten  his  attention  long  upon  any  one  subject  and  fre- 
quently becomes  greatly  depressed,  and  fears  that  he  is  going  insane. 
Memory  for  past  events  is  well  preserved,  and  there  is  no  evident  dis- 
sociation in  thought.  About  a  year  ago  the  patient  began  to  complain  of 
unpleasant  dreams,  always  occurring  when  he  was  half  awake.  The  con- 
tent of  the  dream  always  had  reference  to  the  same  subject;  he  thought 
he  was  fighting  with  a  gigantic  snake,  and  always  experienced  a  sense  of 
great  relief  when  he  awoke.  Within  the  past  two  or  three  months  this 
idea  has  persisted  after  waking,  and  the  patient  fears  that  the  snake  may  be 
real,  and  that  it  is  concealed  under  his  bed  or  somewhere  about  the 
room.  On  being  assured  that  the  idea  about  the  snake  was  merely  the 
product  of  his  imagination,  he  at  first  assented,  but  later  said  that  he  was 
unable  to  get  rid  of  the  idea.  With  the  exception  of  the  marked  depres- 
sion he  has  shown  no  other  mental  symptoms.  On  examination  his 
arteries  were  found  to  be  in  a  remarkable  condition  of  sclerosis,  being 
uniformly  thickened,  and  traceable  high  up  in  his  arm.  The  cardiac 
impulse  was  in  the  anterior  nipple  line,  and  there  was  a  marked  accentua- 
tion of  both  sounds.     Blood-pressure  200.     Urine  negative. 

In  the  great  majority  of  cases  that  come  under  observa- 
tion, particularly  in  hospitals,  the  general  disease  is  so  far 
advanced  and  affects  so  many  organs  that  there  is  little  diffi- 
culty in  referring  any  symptoms  of  alienation  that  may  be 
present  to  these  changes.      At  such  a  time  it  is  difficult  to 


552  PSYCHIATRY 

accomplish  much  in  the  way  of  treatment,  and  for  this  reason 
the  need  for  making  a  diagnosis  at  a  much  earlier  period  is  evi- 
dent. Hence  it  follows  that  a  more  general  appreciation  of 
the  premonitory  signs  on  the  part  of  the  family  physician 
would  unquestionably  avert  serious  disaster  in  not  a  few 
instances. 

In  cases  in  which  there  are  evidences  of  nephritis,  diabetes, 
enlargement  of  the  heart,  or  changes  in  the  arterial  walls,  the 
existence  of  a  concomitant  sclerotic  process  in  the  central  ner- 
vous system  is  probable.  On  the  other  hand,  when  the  sclerosis 
is  limited  to  the  central  nervous  system  its  recognition,  is  far 
more  difficult.  Some  of  the  more  important  of  the  clinical 
signs  of  the  malady  are  seen  in  the  milder  types  of  the  disease, 
generally  referred  to  as  "  the  nervous  forms."  These  cases 
are  not  uncommon  in  both  men  and  women  after  the  fortieth 
year.  The  patients  complain  of  fatigue,  both  mental  and 
physical;  they  recognize  the  fact  that  they  can  not  fix  their 
minds  long  upon  one  subject;  they  are  subject  to  neuralgias 
of  various  forms,  which  occasionally  suggest  attacks  of  mi- 
graine. In  many  instances  there  is  a  singular  subjective  feel- 
ing, nearly  always  present,  of  loss  of  memory.  The  patients 
complain  that  they  can  not  remember  well,  but  on  careful  exam- 
ination it  may  be  impossible  to  prove  the  existence  of  a  positive 
defect.  This  subjective  sense  of  difficulty  in  recalling  past 
events  is  nearly  always  present.  Sometimes  positive  defects 
in  memory,  particularly  for  figures  and  names,  may  be  demon- 
strated. Cramer  has  called  attention  to  the  fact  that  in  many 
instances  associated  with  these  initial  symptoms  at  times  there 
is  a  marked  intolerance  for  alcohol.  Patients  complain  of 
an  inability  to  understand  what  is  said  to  them.  This  is  par- 
ticularly true  if  the  subject  is  at  all  involved  and  not  clearly 
stated.  Slight  temporary  motor  or  sensory  aphasias  may  be 
present.  The  patients,  as  a  rule,  show  some  irritability;  they 
do  not  like  to  be  crossed,  to  have  people  differ  from  them.  At 
times  they  develop  even  a  vague  suspiciousness.  They  feel 
that  their  old  freinds  are  leaving  them.  They  lose  confidence 
in  themselves,  are  oversensitive  in  many  ways,  think  that  their 


ARTERIOSCLEROSIS  553 

acts  are  noted  and  criticised  adversely  by  friends  as  well  as 
by  strangers.  In  some  instances  there  is  a  marked  dulling  of 
the  moral  sense.  This  gives  rise  to  sexual  irregularities, — 
masturbation,  assaults  upon  children,  etc.  Again,  the  finer 
sensibilities  may  be  lost  or  there  may  be  a  tendency  to  become 
obtrusively  egotistical.  The  one  symptom  which  is  very  char- 
acteristic of  all  this  group  of  cases  consists  in  the  remarkable 
insight  that  such  patients  have  regarding  their  own  condition. 
Up  to  a  certain  degree  they  are  able  to  appreciate  and  estimate 
the  value  of  their  symptoms.  They  recognize  the  psychical 
hyperesthesias  as  abnormal.  Personal  characteristics  in  a 
measure  determine  the  clinical  picture.  The  patients  frequently 
complain  that  if  the  symptoms  persist  they  will  lose  their  minds. 
Up  to  a  certain  point  they  are  rational.  They  are  willing  to 
admit  that  they  are  not  bereft  of  will  power,  they  express  the 
desire  of  doing  everything  in  order  to  recover,  but  they  con- 
tinually harp  upon  the  fact  that  if  their  disorder  does  not  abate 
they  will  be  driven  insane.  Individuals  displaying  these  symp- 
toms are  met  with  in  private  practice,  but  in  these  early  stages 
are  seldom  found  in  institutions. 

The  diagnosis  is  frequently  difficult,  as  the  evidence  of 
general  sclerotic  changes  may  be  absent,  although  sometimes 
the  finding  of  sugar  in  the  urine  may  indicate  their  presence 
in  the  central  nervous  system.  The  process  in  some  cases  may 
progress  slowly  and  pass  on  into  the  second  stage.  The  pa- 
tients not  infrequently  die  of  some  intercurrent  trouble  or  there 
may  be  a  long  period  when  the  symptoms  are  more  or  less 
stable.  In  other  cases  the  onset  is  followed  by  a  greater  rap- 
idity of  progression,  the  emotional  disturbances  are  more  prom- 
inent, positive  defects  in  memory  are  present,  the  attention  is 
greatly  impaired,  and  the  subjective  sensations  are,  as  a  rule, 
intensified.  Hallucinations  and  insane  ideas  may  complicate 
the  clinical  picture.  Observers  differ  regarding  the  occurrence 
of  megalomania.  Periods  of  intercurrent  excitement  may 
come  and  go.  Sometimes  mental  depression  is  the  chief  fea- 
ture in  the  case.  The  patients  have  a  woe-begone  appearance, 
sit  in  a  far  corner  of  the  ward  with  the  eyes  fixed  upon  the 


554  PSYCHIATRY 

ground  and  the  corners  of  the  mouth  often  slightly  drooping. 
They  complain  of  being  ruined,  of  having  committed  flagrant 
sins  for  which  they  can  not  be  forgiven.  They  affirm  that  it  is 
wrong  for  them  to  be  in  the  hospital,  that  they  do  not  deserve 
such  good  treatment,  that  they  should  be  killed,  even  tortured, 
on  account  of  their  wrong-doing.  In  some  cases  they  adhere 
to  these  ideas  with  great  tenacity,  while  in  others  they  can  be 
diverted  temporarily.  Emotional  instability  is  often  present 
and  fits  of  laughing  and  crying  often  alternate.  In  some  cases 
interest  may  be  suddenly  aroused  by  the  visit  of  a  friend  or 
by  the  occurrence  of  a  sudden  and  unexpected  event,  but  this 
change  is  only  transitory.  There  may  be  marked  motor  rest- 
lessness, which  displays  itself  in  various  ways.  Sometimes 
the  patient  will  wander  aimlessly  about  in  a  fairly  good-humor 
until  an  attempt  is  made  to  restrain  him,  but  then  he  becomes 
violent.  Such  persons  not  infrequently  exhibit  a  curious  ten- 
dency to  collect  various  articles  or  objects  lying  about  the 
wards  or  that  have  been  gathered  by  them  on  their  walks  about 
the  hospital  grounds.  Transitory  delirious  states  are  not  at 
all  infrequent.  At  first  these  are  of  short  duration,  but  as  the 
disease  progresses  they  become  longer  and  the  delirium  is 
more  constant.  The  focal  lesions  which  may  occur  during  the 
course  of  the  cases  are  not,  as  a  rule,  responsible  for  the  mental 
symptoms.  This  fact  is  particularly  important,  and  should  be 
borne  in  mind  more  especially  in  connection  with  the  post- 
apoplectic dementias.  In  reality  the  symptoms  of  alienation 
are  referable  to  the  accompanying  arterial  changes.  In  these 
severer  cases  the  patients  still  preserve  a  remarkable  insight 
into  their  own  condition. 

In  some  instances  the  symptoms  displayed  during  the 
course  of  the  disease  are  of  forensic  importance.  Patients  suf- 
fering from  a  mild  degree  of  arteriosclerosis,  with  symptoms 
of  alienation  that  are  apparently  out  of  proportion  to  the  physi- 
cal changes>  not  infrequently  are  brought  before  the  courts  for 
having  committed  acts  of  violence.  Various  forms  of  assault, 
theft,  arson,  the  infliction  of  injury  upon  members  of  the  family 
or  friends  without  any  provocation,  etc.,  have  been  reported. 


ARTERIOSCLEROSIS  555 

Our  knowledge  regarding  the  mental  diseases  associated 
with  arteriosclerosis  practically  dates  from  the  early  attempts 
made  to  differentiate  the  spurious  from  the  typical  cases  of 
dementia  paralytica.10  Klippel,  in  1891,  described  his  pseudo- 
paralyse  generate  arthritique,  a  condition  essentially  the  same 
as  cerebral  atrophy  due  to  arteriosclerosis.  In  1894  Binswan- 
ger  described  the  cerebral  cortical  atrophy  associated  with  vas- 
cular disease,  and  pointed  out  in  this  connection  certain  facts 
which  were  supposed  to  be  important  in  the  differential  diag- 
nosis of  the  two  conditions.  In  reporting  these  investigations 
he  referred  to  the  occurrence  of  a  diffuse  chronic  subcortical 
encephalitis.  About  the  same  time  Alzheimer  described  a  con- 
dition to  which  he  gave  the  name  of  perivascular  sclerosis.  In 
these  studies  he  emphasized  the  important  clinical  fact  that 
although  there  might  be  marked  sclerotic  changes  in  the  vessels 
of  the  central  nervous  system,  the  process  was  absent  or  only 
present  to  a  limited  degree  in  other  organs.  This  important 
fact  renders  the  diagnosis  in  many  instances  extremely  difficult. 

In  the  milder  cases  one  finds  occasionally  small  areas  of 
softening  with  general  dilatation  of  the  perivascular  spaces 
and  an  increase  of  the  glia.  The  ganglion  cells  show  marked 
pigmentation,  but,  as  a  rule,  the  medullated  fibres  are  intact. 
The  vessels  show  the  characteristic  arteriosclerotic  changes.  In 
the  glia  a  few  spider-cells  are  found,  but  compound  granular 
corpuscles  are,  as  a  rule,  absent. 

In  the  second  group  of  cases  there  is  generally  a  marked 
diminution  in  the  weight  of  the  brain  and  dilatation  of  the 
ventricles ;  the  white  substance  has  a  curious  gray  appearance, 
and  not  infrequently  many  miliary  aneurysms  are  found.  The 
ganglion  cells  as  well  as  the  fibres  are  little  altered.  The 
arteriosclerotic  areas  may  be  numerous;  there  is  marked  in- 
crease in  the  spider-cells;    compound  granular  corpuscles  are 

10  Alzheimer :  Centralblatt  f.  Nervenheilk.  u.  Psych.,  xxv.  Jahrgang, 
Nr.  149,  15  Juni,  1902,  S.  399.  Idem :  Histologische  Studien  zur  Differen- 
tialdiagnose  der  progressive  Paralyse.  Nissl,  Franz :  Zur  Histopathologic 
der  paralytischer  Rindenerkrankung.  Histolog.  u.  Histopatholog.  Arbeit, 
iiber  die  Grosshirnrinde,  Herausgeg.  von  Fr.  Nissl,  Bd.  i,  Jena,  1904. 


556  PSYCHIATRY 

generally  present.  Alzheimer  distinguishes  the  following  con- 
ditions : 

(i)  A  chronic  subcortical  encephalitis  first  described  by 
Binswanger.  Only  the  deeper  fibre  tracts  are  affected,  and  the 
cortex  proper  is  practically  intact.  In  these  cases,  in  addition  to 
the  psychical  symptoms  noted,  as  a  rule,  various  disturbances 
occur  that  point  to  local  lesions.  The  differential  diagnosis 
between  these  and  certain  atypical  cases  of  dementia  paralytica 
is  frequently  difficult.  With  the  exercise  of  great  care  and  a 
careful  study  Alzheimer  believes  that  it  is  possible  to  diagnose 
such  cases  during  life.  In  the  cases  of  atypical  paresis,  as  a 
rule,  there  are  evidences  which  point  to  the  existence  of  a  more 
general  destructive  process  than  is  the  case  in  patients  affected 
with  arteriosclerosis.  In  this  latter  group  of  cases  the  lesions 
may  be  limited  to  one  or  more  convolutions  and  the  process 
may  be  more  intense  in  one  area  than  in  the  other,  but  the 
tendency  is  for  the  symptoms  referable  to  focal  lesions  to  be- 
come prominent  in  the  clinical  picture.  This  is  equally  true 
in  regard  to  the  psychical  anomalies.  In  the  senile  dementias 
as  well  as  in  the  cases  of  dementia  paralytica  there  is  a  general 
impairment  of  the  intellectual  faculties.  In  the  cases  of  arterio- 
sclerosis, on  the  other  hand,  some  psychical  functions  may  be 
intact,  while  others  are  markedly  disturbed.  As  has  been 
pointed  out,  cases  of  arteriosclerosis  by  their  symptoms  sug- 
gest the  occurrence  of  focal  lesions  and  to  the  casual  observer 
are  more  plainly  indicative  of  organic  brain  disease  than  are 
many  cases  of  senile  or  paralytic  dementia.  The  cases  of  senile 
dementia  with  focal  lesions  are  frequently  as  difficult  to  dis- 
tinguish from  true  arteriosclerosis  as  are  some  of  the  atypical 
cases  of  paresis.  In  the  former  group  of  cases,  as  Alzheimer 
affirms,  it  is  possible  to  obtain  glimpses,  as  it  were,  of  con- 
ditions which  are  more  or  less  characteristic  of  senile  dementia 
and  which  indicate  the  presence  of  a  general  rather  than  a 
localized  cortical  lesion. 

(2)  A  destructive  process  more  or  less  limited  to  the  cor- 
tex. The  focal  areas  are  wedge-shaped  with  the  base  of  the 
wedge  external.     These  areas  are  occupied  almost  exclusively 


ARTERIOSCLEROSIS  557 

by  a  thick  glia  network.  The  longer  association  tracts  are 
intact.  Along  some  of  the  capillaries  there  are  evidences  of 
beginning  softening. 

(3)  Here  we  have  to  do  with  a  perivascular  gliosis.  In 
the  cortex,  as  well  as  in  the  deeper  portions  of  the  convolutions, 
we  meet  with  circumscribed  areas  in  which  the  nerve-cells  have 
been  destroyed  and  replaced  by  a  marked  increase  in  the  glia. 
These  areas  usually  correspond  with  the  regional  distribution 
of  the  affected  arteries.  An  important  symptom  in  differen- 
tiating these  cases  from  the  dementias  is  the  so-called  senile 
epilepsy.  The  clinical  forms  recognized  are  generally  two — 
one  in  which  the  psychical  aberration  during  or  following  the 
attack  is  not  great  and  the  symptoms  are  apparently  due  merely 
to  local  disturbances  in  the  cortical  circulation;  in  the  other 
group  of  cases  evidences  of  marked  focal  lesions  are  more 
prominent.  Following  an  attack  there  are  evidences  of  paraly- 
sis, narrowing  of  the  field  of  vision,  etc. 

In  these  milder  forms  of  the  disease  the  diagnosis  rests 
largely  upon  the  nervousness,  the  psychical  and  physical  fa- 
tigue, headache,  the  subjective  disturbances  of  memory,  attacks 
of  vertigo,  and  the  tendency  to  remissions.  The  period  at 
which  the  sclerotic  process  begins  varies  in  different  individuals 
and  depends  upon  many  causes.  A  general  discussion  of  this 
subject  can  not  be  entered  upon  here.  Suffice  it  to  say  that 
aside  from  the  ordinary  factors  enumerated,  such  as  syphilis, 
alcohol,  etc.,  there  seems  to  be  in  certain  families  a  marked 
predisposition  to  these  diseases  of  the  vascular  system.  More- 
over, in  certain  localities  the  disease  is  more  common  than  it 
is  elsewhere. 

The  severer  cases,  especially  when  the  symptoms  of  aliena- 
tion are  at  all  marked,  are  much  better  off  in  an  institution 
where  they  can  be  properly  cared  for.  The  bodily  weight 
should  be  carefully  watched.  If  there  is  a  marked  decrease,  the 
patient  is  better  off  in  bed.  The  diet  should  consist  largely  of 
milk.  The  periods  of  excitement  may  be  benefited  by  pro- 
longed baths.  The  administration  of  as  few  drugs  as  possible 
is  indicated.     Insomnia  may  sometimes  be  relieved  by  giving 


558  PSYCHIATRY 

the  patient  a  lukewarm  pack  when  the  bath  is  not  indicated. 
This  may  be  followed  by  some  light  nourishment,  such  as  a 
glass  of  milk.  The  severer  and  more  temporary  forms  of 
excitement  are  best  treated  by  the  use  of  sulphonal,  bromides, 
chloral,  morphin,  or  hyoscyamin  in  small  doses. 

The  general  treatment  of  these  cases  is  largely  sympto- 
matic. In  the  earlier  stages,  as  soon  as  there  is  any  suspicion 
of  a  sclerosis  of  the  vessels  in  the  central  nervous  system,  the 
patients  must  be  removed  as  far  as  possible  from  all  responsi- 
bilities. They  should  be  advised  to  give  up  everything  which 
will  subject  them  to  unnecessary  strain,  either  mental  or  physi- 
cal. Life  in  the  country  is  preferable  to  that  in  the  city.  The 
diet  must  be  light  and  nourishing;  plenty  of  exercise,  not 
severe,  in  the  open  air  is  indicated.  If  the  sense  of  fatigue  is 
well  marked,  the  patients  may  do  well  to  undergo  for  a  short 
time  a  rest-cure,  during  which  time  they  are  confined  to  bed, 
kept  on  a  fluid  diet,  given  massage,  and  allowed  to  have  an  oc- 
casional Turkish  bath,  best  given  under  medical  supervision. 
Stimulants  of  all  kinds  must  be  avoided.  The  bowels  must  be 
kept  well  regulated.  In  the  poorer  class  of  patients  who  come 
to  the  dispensaries  and  hospitals  a  great  deal  can  be  done  by 
regulating  the  diet  and  by  advising  the  patient  to  carefully 
avoid  all  excesses.  The  number  of  meals  should  be  increased 
to  five  or  six  in  the  twenty-four  hours  instead  of  three.  This, 
as  a  rule,  obviates  the  possibility  of  a  patient  overtaxing  his 
digestion  at  any  one  time. 

Syphilis.11 — Since  the  middle  of  the  last  century  the 
question  as  to  whether  syphilis  gives  rise  to  psychoses  which 
can  in  any  sense  be  characterized  as  distinctive  of  this  disease 
has  been  much  debated.  Although  no  satisfactory  solution  has 
as  yet  been  arrived  at,  much  of  the  work  of  recent  investigators 
has  at  least  been  beneficial  in  re-formulating  the  problems  to 
be  solved.     As  has  already  been  said,  it  is  now  possible  in  a 


11  Rumpf :  Die  syphilitischen  Erkrankungen  des  Nervensystems,  1887 
Kowalewsky :  Arch.  f.  Psych.,  xxvi,  2.  Nonne :  Syphilis  und  Nerven- 
system.     Berlin,  1902. 


SYPHILIS 


559 


great  number,  if  not  in  all,  of  the  cases  to  differentiate  the 
syphilitic  from  the  paretic  process,  and  the  arteriosclerotic  from 
the  senile  group ;  and  at  the  same  time  we  have  arrived  at  more 
definite  ideas  about  certain  other  conditions.  In  1877  Erlen- 
meyer  affirmed  that  the  mental  anomalies  occurring  during 
syphilis  might  be  divided  into  the  so-called  simple  psychoses 
and  those  in  which  disturbances  of  motility  and  sensibility  are 
met  with,  the  condition  then  bearing  a  striking  resemblance  in 
many  of  its  phases  to  general  paresis.  Fournier  speaks  of  a 
chronic  depressed  state  in  which  there  is  a  general  intellectual 
impairment,  and  a  second  more  acute  type  characterized  by 
definite  periods  of  excitement  and  delirium,  which  he  holds 
are  directly  attributable  to  the  action  of  irritating  stimuli  upon 
the  cerebral  cortex.  Heubner  12  differentiates  three  distinct 
forms  of  aberration  associated  with  cerebral  syphilis :  ( 1 )  In 
the  first  the  pathological  process  is  more  or  less  localized,  gum- 
mata  being  present  in  the  convexity  of  the  brain  associated 
with  conditions  of  depression  or  excitement  with  accompany- 
ing defect  in  memory,  intelligence,  and  in  the  whole  person- 
ality. In  this  form  aphasia,  various  local  paralyses,  and  epi- 
leptiform attacks  are  often  encountered.  (2)  In  the  second, 
where  the  arteritis  is  confined  to  the  basal  portions  of  the  brain, 
the  symptoms  are  those  of  a  simple  dementia.  (3)  In  the  third 
form,  where  the  vascular  changes  are  more  pronounced  in  the 
cortex,  the  most  prominent  manifestations  are  delirium,  partial 
loss  of  consciousness,  together  with  impulsive  acts  of  various 
kinds.  These  investigations  were  carried  still  further  by  Kowa- 
lewsky.13  The  relation  of  the  syphilitic  infection  to  neuras- 
thenic and  hysterical  states  was  studied  by  Charcot  and  his 
pupils.     A  convenient  clinical  division  of  the  aberrations  asso- 


22  Von  Ziemssen's  Handbuch,  Bd.  xi,  1. 

13  Syphilis  und  Neurasthenic  Centralbl.  f.  Nervenheilk.,  1893,  iii. 
Zur  Lehre  von  der  syphilitischen  Spinalparalyse  von  Erb.  Neurol.  Cen- 
tralbl., 1893,  Nr.  12.  Die  functionellen  Nervenkrankheiten  und  die  Syph- 
ilis. Arch.  f.  Psych.,  Bd.  xxvi.  Geistesstorungen  bei  Syphilis.  Allg. 
Ztschr.  f.  Psych.,  Bd.  1,  1894.  Syphilitische  Epilepsie.  Berl.  klin.  Wchn- 
schr.,  1894,  Nr.  4. 


560  PSYCHIATRY 

dated  with  syphilis  corresponding  with  the  three  periods  is  as 
follows :  ( i )  Those  occurring  after  the  arrest  in  development 
of  the  chancre.  (2)  Those  encountered  during  the  efflores- 
cence, this  period  extending  to  the  time  when  in  cases  which 
have  not  been  promptly  treated  the  arterial  and  meningeal  le- 
sions make  their  appearance.  (3)  Those  belonging  to  the 
period  during  which  the  gummatous  growths  develop  and  the 
arterial  disease  becomes  marked. 

During  the  first  period  the  mental  symptoms  are  those 
belonging  to  an  acute  infectious  disease.  Among  the  milder 
disturbances  noted  are  various  manifestations  of  hysteria  and 
neurasthenia.  These  may  or  may  not  be  associated  with 
marked  mental  depression,  the  individual  being  greatly  per- 
turbed on  account  of  the  character  of  the  disease  from  which 
he  is  suffering,  and  being  unable  to  divert  his  mind  from  the 
possible  terrible  effects  of  the  malady  which  he  is  continually 
picturing  to  himself.  These  cases  are  frequently  described  as 
instances  of  syphilophobia.  Occasionally  in  neurasthenic  sub- 
jects these  fears  are  so  intense  that  a  hypochondriacal  state 
supervenes  from  which  it  is  almost  impossible  to  arouse  the 
patient.  In  other  instances,  instead  of  depression,  we  meet 
with  marked  maniacal  excitement.  In  all  probability,  how- 
ever, in  such  cases  the  infection  acts  merely  as  a  provocative 
agent  in  precipitating  an  attack  of  manic-depressive  insanity, 
amentia,  or  some  other  psychosis. 

States  of  depression  or  excitement  are  much  more  apt  to 
occur  during  the  period  of  efflorescence,  and  here  a  symptom- 
complex  may  develop  which  suggests  the  acute  delirium  asso- 
ciated with  a  rise  of  temperature  followed  by  indications  of 
more  or  less  complete  collapse,  convulsive  seizures,  and  symp- 
toms of  meningeal  invasion. 

In  the  third  stage  the  onset  of  the  mental  symptoms  is, 
as  a  rule,  more  gradual.  In  many  instances  there  is  apparently 
a  general  impairment  of  the  mental  and  physical  vigor.  At 
first  there  may  be  some  confusion,  although  in  the  early  stages 
the  patient  retains  a  fairly  accurate  insight  into  his  own  con- 
dition.     Some  authors   are   inclined   to   distinguish  between 


SYPHILIS  561 

simple  luetic  dementia  and  the  so-called  pseudoparesis  of  luetic 
origin.  As  these  two  groups  of  cases  are  apt  to  resemble  each 
other  in  many  ways,  it  is  impossible  to  differentiate  clearly  be- 
tween them.  In  some  instances,  however,  we  meet  with  indi- 
viduals who  show  an  insidious  and  progressive  blunting  of  all 
their  mental  faculties  with  marked  loss  of  insight  and  defect 
in  memory,  and  who  ultimately  develop  an  apathetic  dementia. 
During  the  course  of  the  disease  epileptiform  or  apoplectiform 
attacks  may  or  may  not  occur.  In  other  instances  variations 
in  the  affective  state  are  noted;  the  individual  is  sometimes 
depressed,  at  other  times  markedly  exhilarated,  so  much  so  that 
it  is  frequently  impossible  to  differentiate  this  mental  condition 
from  that  which  occurs  in  general  paresis.  In  some  instances 
ideas  of  persecution  develop,  the  individual  becoming  markedly 
suspicious,  not  only  of  members  of  his  own  family,  but  of  all 
with  whom  he  is  brought  into  contact.  As  a  rule,  however, 
these  ideas  are  more  or  less  transient  and  are  seldom  persistent 
or  intense  enough  to  supply  more  than  a  temporary  motive  for 
conduct.  Such  individuals,  particularly  in  the  early  stages,  are 
apt  to  show  marked  intolerance  for  alcohol  as  well  as  a  loss 
of  the  power  of  concentrating  the  attention  or  energies.  They 
neglect  their  work,  no  longer  care  for  their  families,  and  exhibit 
an  indifference  to  all  but  the  immediate  necessities  connected 
with  their  own  existence.  In  the  cases  which  simulate  general 
paresis  we  may  have  impairment  of  the  light  reflexes,  some 
difference  in  the  facial  innervation,  marked  tremor  in  the  mus- 
cles of  the  face,  tongue,  and  extremities,  and  a  complex  of 
symptoms  which  it  is  frequently  impossible  at  the  moment  to 
differentiate  from  those  of  general  paresis.  These  pseudo-- 
pareses  of  syphilitic  origin  may,  however,  be  recognized  by 
the  slow  progressiveness  of  the  clinical  features,  the  tendency 
to  long  remissions,  and  sometimes  by  the  definite  benefit  de- 
rived from  antisyphilitic  treatment.  In  some  cases  a  euphoria 
similar  to  that  described  under  the  expansive  type  of  general 
paresis  develops.  In  these  dementing  cases  the  course  is,  as 
a  rule,  protracted,  death  intervening  only  after  a  period  "of 
from  ten  to  twenty  years  from  the  onset.    As  a  rule,  when  the 

36 


562  PSYCHIATRY 

dementia  is  marked,  little  can  be  expected  from  treatment,  and 
permanent  mental  defects  are  nearly  always  noted,  although 
the  cases  may  be  differentiated  from  those  of  genuine  dementia 
paralytica  by  the  apparent  cessation  of  the  disease  process  and 
the  remissions  extending  over  several  years.  The  epileptiform 
attacks  in  these  cases  are  apt  to  be  much  more  frequent  than 
in  general  paresis.  The  so-called  juvenile  paretics,  as  far  as 
the  present  evidence  indicates,  should  be  classed  as  hereditary 
syphilitics,  as  they  usually  present  more  of  the  symptoms  of 
cerebral  syphilis  than  of  general  paresis. 

Treatment. — In  the  group  of  cases  described  under  the 
first  and  second  heads  an  energetic  antisyphilitic  treatment 
often  brings  about  recovery.  Particularly  desirable  in  these 
early  cases  is  the  use  of  inunctions.  If  any  nervous  symptoms 
develop  it  is  better  that  the  patient  be  isolated  for  a  time,  kept 
quietly  in  bed,  given  frequent  baths  or  packs,  and  a  diet  re- 
stricted principally  to  milk.  In  the  more  acute  cases,  where 
maniacal  symptoms  appear,  the  individual  should  be  trans- 
ferred at  once  to  a  hospital  where  he  can  be  carefully  watched 
and  the  administration  of  mercury  and  iodides  pursued  rapidly 
to  the  point  of  tolerance.  In  the  group  of  symptoms  which 
develop  later  in  the  infection,  the  therapy  is  apt  to  be  less  satis- 
factory, although  excellent  results  often  follow  the  administra- 
tion of  large  doses  of  the  iodides.  It  is  better  to  begin  with 
small  doses  of  a  saturated  solution  and  rapidly  increase,  add- 
ing one  drop  to  the  amount  three  times  a  day.  In  this  way  the 
patient  can  soon  be  made  to  take  from  ioo  to  200  grains  daily. 
After  large  doses  have  been  given  for  four  or  six  weeks  the 
drug  should  be  withdrawn  and  the  patient  allowed  to  go  with- 
out any  medication  for  a  week  or  ten  days,  after  which  another 
period  of  treatment,  lasting  a  month  or  six  weeks,  should  be 
begun.  In  many  of  these  mental  abnormalities  occurring  in 
neurotic  and  debilitated  individuals  tonics — iron,  arsenic,  and 
strychnin — prove  valuable  adjuncts.  The  diet  should  be  light 
but  nourishing,  and  in  the  absence  of  too  acute  symptoms  a 
life  in  the  open  air  is  all-important. 

Pathology. — A  great  variety  of  pathological  changes  are 


SYPHILIS  563 

demonstrable  in  the  central  nervous  system  as  a  result  of  syphi- 
litic infection.  The  characteristic  lesions  in  the  blood-vessels 
(see  chapter  on  Dementia  Paralytica)  are  nearly  always  pres- 
ent, but,  as  has  been  pointed  out  elsewhere,  the  marked  infil- 
tration does  not,  as  a  rule,  affect  the  adventitial  sheath.  We 
meet  with  frequent  evidence  of  the  formation  of  new  vessels, 
and,  according  to  Nissl,  the  hypertrophy  of  the  endothelial 
lining  of  the  vessels  is  also  a  source  for  the  new  vessel  forma- 
tion, small  capillaries  penetrating  the  cells.  In  not  a  few  syphi- 
litic cases  many  of  the  localizing  symptoms — for  instance,  vari- 
ous forms  of  paresis — are  to  be  explained  by  the  occurrence  of 
areas  of  softening,  whereas  in  the  cases  of  paretic  dementia 
they  are  more  apt  to  be  associated  with  changes  in  the  minute 
structure  of  the  cortex.  The  nerve-elements  themselves  are 
often  swollen,  and  if  a  section  of  the  cortex  from  a  case  of 
syphilitic  disease  is  compared  with  one  taken  from  the  normal 
brain  an  apparent  increase,  not  only  in  the  size  of  the  nerve- 
elements,  but  also  in  the  formation  of  new  vessels,  can  be 
detected.  The  size  as  well  as  the  number  of  glia-elements  is 
often  greatly  increased,  and  in  certain  places  where  the  nerve- 
elements  have  been  destroyed  we  have  a  thick  matting  of  the 
glia-fibres  (Nissl's  Gliarasen).  The  diminution  in  the  num- 
ber of  the  nerve-fibres  is  not  nearly  as  striking  as  in  the  cases 
of  general  paresis.  For  a  full  description  of  the  various  gum- 
matous formations  the  reader  is  referred  to  the  various  text- 
books on  general  pathology. 


CHAPTER    XX 

THE  PARANOIA  GROUP  1 

The  term  paranoia  was  formerly  used  to  designate  cases 
of  alienation  in  which  the  insane  ideas  were  expressed  in  such 
a  way  as  to  suggest  a  certain  degree  of  systematization  or  con- 
nection, being  also  developed  with  a  semblance  of  logical  se- 
quence and  marked  by  stability.  Such  cases  were  referred  to 
as  partial  or  systematized  deliria,  and  were  supposed  to  stand 
in  sharp  contrast  to  the  so-called  general  deliria  of  mania  or 
melancholia.  Furthermore,  it  was  thought  that  paranoia  was 
more  common  in  individuals  who  prior  to  the  onset  of  the 
alienation  had  shown  some  predisposition  towards  nervous  or 
mental  disorders. 

For  a  long  time  in  the  history  of  psychiatry  paranoia  was 
regarded  as  one  of  the  stable  symptom-complexes  concerning 
whose  origin  and  development  it  was  impossible  to  gain  any 
very  clear  conception,  and  alienists  were  apparently  content 
with  a  merely  casuistical  study  of  cases  and  a  series  of  cata- 
logues of  symptoms,  so  that  each  new  phase  in  the  social  life 
seemed  to  be  represented  by  a  special  type  of  paranoia.  The 
text-books  on  psychiatry  abounded  in  such  titles  as  the  per- 
secutory, religious,  hypochondriacal,  sexual,  or  hysterical  types 
of  paranoia,  and  every  slight  variation  in  the  clinical  picture 
was  accepted  as  sufficient  justification  for  the  immediate  for- 
mation of  a  new  group.  Gradually,  however,  it  became  ap- 
parent, as  has  been  shown  in  the  chapter  dealing  with  insane 
ideas,  that  the  mere  systematization  and  persistence  of  insane 
ideas  could  not  be  taken  as  specific  characteristics  of  a  disease 
entity.     As  soon  as  alienists  began  to  study  the  development, 

1  Berze :  Ueber  das  Primarsymptom  der  Paranoia.  Halle,  1903.  Mc- 
Donald, W. :  The  Present  Status  of  Paranoia.  Am.  Journ.  Insan., 
1904,  January,  vol.  lx,  No.  3.  Schultze :  Bemerkungen  zur  Paranoiafrage. 
Deutsch.  med.  Wchnschr.,  1904,  Januar  14-21,  Nr.  3-4. 

564 


PARANOIA  565 

course,  and  termination  of  the  various  symptom-complexes,  it 
was  noted  that  clinical  pictures  remarkably  similar  in  many 
respects  could  develop  out  of  what  were  primarily  essentially 
different  conditions,  and  that  neither  the  logical  sequence  nor 
the  persistence  of  the  ideas,  with  the  retention  of  a  fair  degree 
of  intellectual  power,  could  be  justly  regarded  as  a  dominant 
characteristic  any  more  than  the  temperature  curve  could  be 
considered  the  sole  specific  means  of  differentiating  febrile  dis- 
orders. As  soon  as  the  clinical  method  of  investigation  was 
given  a  fair  trial  it  was  found  that  it  was  possible  to  remove 
from  this  group  a  variety  of  paranoioid  states  which  were 
found  to  be  merely  transitional  phases  belonging  to  other  psy- 
choses. Formerly  it  had  been  the  custom  to  distinguish  be- 
tween the  so-called  acute  and  chronic  cases  of  paranoia,  the 
curability  of  the  former  being  a  matter  of  common  observation. 
But  the  recognition  of  such  a  distinction  soon  led  investigators 
to  inquire  whether  the  acute  process  with  merely  transitory 
paranoioid  conditions  might  not  be  fundamentally  different 
from  the  chronic  states.  It  was  noted,  for  example,  that  many 
of  the  more  protracted  cases  of  delirium  tremens  in  which  the 
insane  ideas  were  arranged  with  some  degree  of  logical  se- 
quence persisted  for  a  considerable  length  of  time  unchanged, 
eventually  clearing  up  and  disappearing,  and  that  finally  the 
patient  recovered  completely.  Gradually,  as  it  became  clear 
that  the  same  mental  state  was  observable  in  a  variety  of  other 
conditions — for  example,  in  the  acute  confusional  insanity  of 
the  English  writers  and  in  the  amentia  of  Meynert — alienists 
awakened  to  an  appreciation  of  the  fact  that  the  grouping  of 
these  acute  forms  with  the  chronic  systematized  insanities  was 
based  merely  upon  the  existence  of  certain  superficial  simi- 
larities. Thus,  in  connection  with  the  study  of  a  large  group 
of  cases  which  led  to  the  present  formulation  of  ideas  in  regard 
to  dementia  prsecox,  it  became  apparent  that  a  great  variety 
of  chronic  systematized  forms  of  alienation  characterized  by 
a  terminal  dementing  process  with  many  specific  symptoms  in 
common,  such  as  stereotypies,  negativism,  etc.,  bore  only  a  su- 
perficial resemblance  to  paranoia.    More  recently  the  attention 


566 


PSYCHIATRY 


of  alienists  has  been  directed  to  the  occurrence  of  paranoioid 
forms  of  manic-depressive  insanity,  and  here  again  it  has 
been  shown  that  in  addition  to  the  mental  condition  of  the 
patient  there  are  symptoms  of  a  more  purely  physical  charac- 
ter which  serve  to  differentiate  these  cases  from  the  so-called 
paranoia  group.  Whether  the  majority  of  the  chronic  cases 
develop  out  of  an  acute  paranoiic  condition  is  still  question- 
able. 

After  all  these  deductions  have  been  made  we  are  still  left 
with  a  small  residual  group  of  cases  which  can  not  as  yet  be 
definitely  assigned  to  any  of  the  psychoses  hitherto  described. 
And  it  is  to  this  more  or  less  indefinite  assemblage  of  cases, 
representatives  of  which  constantly  fall  under  the  observation 
of  the  physician,  that  attention  will  be  briefly  directed  in  the 
present  chapter.  Wernicke  has  defined  the  characteristics  of 
this  group  of  cases  as  consisting  in  a  falsification  of  the  con- 
tent in  conjunction  with  a  normal  activity  of  consciousness. 
As  the  acute  forms  of  paranoia  are  variously  classified  under 
the  different  psychoses  of  which  they  form  an  integral  part,  it 
only  remains  to  consider  the  so-called  residual  forms  in  which 
the  active  disease  process  has  either  run  its  course  and  become 
stationary  or  continues  to  develop  only  slowly  and  insidiously. 
Whether  a  clinical  differentiation  upon  this  basis  can  be  main- 
tained depends  altogether  upon  the  facts  which  the  histories 
of  cases,  followed  through  long  periods  of  time,  bring  to  light. 
Reference  has  already  been  made  in  the  earlier  sections  to  the 
necessity  of  studying  carefully  the  pathogenesis  of  the  various 
forms  of  paranoia.  Admitting  that  in  the  acme  of  the  disease 
the  main  features  of  many  of  the  cases  consist  in  an  essential 
absence  of  disturbances  in  the  affective  life  and  a  predominance 
of  more  purely  intellectual  defects,  too  sweeping  conclusions 
based  upon  a  partial  truth  are  still  unjustifiable.  For  the  earlier 
that  we  see  many  of  the  cases  in  which  the  intellectual  defects 
are  prominent,  the  more  convincing  is  the  evidence  that  among 
the  first  disturbances  in  the  mental  life  the  affective  anomalies 
play  an  important  part.  For  this  reason  the  former  attempts 
to  bring  the  paranoioid  states,  as  representing  purely  intellec- 


PARANOIA  567 

tual  defects,  into  such  sharp  contrast  with  mania  and  melan- 
cholia are  not  supported  by  our  present  knowledge.  Berze 
refers  the  primary  disturbance  in  paranoia  neither  to  an  intel- 
lectual nor  to  an  emotional  state,  but  to  an  anomaly  in  apper- 
ception of  such  a  character  that  the  process  of  bringing  the 
psychic  content  into  the  field  of  consciousness  is  impaired. 
This  anomaly  of  function  results  in  the  impairment  of  the  ap- 
perception, and  upon  this  derangement  depends  the  lack  of 
judgment  and  defective  critical  power  of  the  paranoiic.  Fur- 
thermore, this  defect  in  function  retards  the  departure  of  the 
idea  from  the  field  of  consciousness  when  the  representation 
has  once  gained  access  to  it,  and  this  anomaly  in  turn  gives 
rise  to  a  tendency  to  establish  forced  relationships  between  the 
various  ideas  in  consciousness.  These  mental  defects,  of  which 
the  patient  himself  is  in  part  subjectively  appreciative,  are  in 
all  probability  the  basis  of  the  subsequent  ideas  of  persecution. 
Hallucinations,  when  they  occur,  are  neither  primary  nor  essen- 
tial factors  in  the  development  of  paranoia.  As  a  further 
result  of  his  observations  Berze  concludes  that  the  individual 
who  is  the  subject  of  paranoia  suffers  from  a  psychic  defect 
which  can  not  be  designated  as  an  evidence  of  feeble-minded- 
ness  in  the  ordinary  sense  of  the  word,  and  that  the  primary 
disturbances  are  not  in  any  sense  affective.  This  point  of  view, 
although  extremely  suggestive,  can  not  be  considered  as  more 
than  an  interesting  and  possibly  helpful  hypothesis. 

Specht 2  affirms  that  in  studying  cases  of  paranoia  atten- 
tion must  be  paid  to  several  factors,  such  as  the  direction  and 
form  of  the  insane  ideas  as  well  as  the  material  out  of  which 
they  are  developed.  According  to  this  same  observer,  the 
psychogenetic  factor  of  greatest  importance  is  the  direction 
or  trend  given  by  the  idea  as  determined  by  the  individuality 
of  the  patient.  Thus  the  ego  becomes  the  centre  of  any  false 
system  of  thought,  and  as  yet  clinicians  have  failed  to  empha- 
size sufficiently  the  importance  of  the  egocentric  character  of 


2  Ueber  den  pathologischen  Effekt  in  der  chronischen  Paranoia.     Er- 
langen  und  Leipzig,  1901. 


568 


PSYCHIATRY 


every  insane  idea.  The  importance  of  the  affective  disturbances 
and  the  fact  that  these  ideas  are  born  of  emotional  states  in 
part  explain  their  incorrigibility.  The  genesis  of  the  ideas 
may  be  attributed  not  to  the  preponderance  of  one  pronounced 
emotional  state,  but  rather  to  a  mixture  of  factors.  Pure  de- 
pression concentrates  the  patient's  attention  too  minutely, 
while  exaltation  or  exhilaration  diffuses  it.  The  systematized 
insane  idea  springs  from  a  complex  emotional  state  in  which 
no  one  tone  is  alone  dominant.  The  clinical  proof  for  this  is 
found  in  the  paranoioid  states  which  frequently  develop  in 
association  with  manic-depressive  insanity. 

With  our  present  knowledge  the  ultimate  solution  of  the 
whole  question  can  not  be  derived  from  a  study  of  comparative 
symptomatology,  but  must  depend  upon  the  perfection  and 
elaboration  of  clinical  histories  to  such  an  extent  that  the  de- 
velopment, course,  and  termination  of  the  doubtful  cases, 
extending  over  long  periods  of  years,  can  readily  and  minutely 
be  investigated.  The  mere  refinement  of  the  psychological 
analysis,  however  admirable  it  may  be,  cannot  give  us  any  real 
insight  into  the  natural  history  of  the  disease  with  which  we 
are  dealing;  neither  can  the  protracted  duration  of  certain 
cases  be  looked  upon  as  a  safe  criterion  in  differentiation.  It 
is  not  at  all  improbable  that  whereas  a  disease  process  in  one 
individual  may  run  its  course  in  a  few  months,  in  another 
person,  under  different  surroundings  and  a  stronger  mental 
resistiveness,  it  may  be  prolonged  for  a  period  of  years. 

The  remarkable  confusion  that  results  from  the  mere 
epochal  study  of  paranoiic  states,  without  any  genuine  and 
steady  attempt  to  trace  the  connection  between  apparently  dis- 
similar conditions,  is  well  exemplified  in  the  study  of  the  so- 
called  original  paranoia.  According  to  Sander,3  who  first  used 
the  term,  this  form  of  chronic  systematized  insanity  develops 
in  individuals  who  early  in  life  have  shown  certain  abnormali- 
ties in  character  with  a  marked  inclination  to  indulge  in  con- 


a  Sander,  W. :    Ueber  eine  spezielle  Form  der  primaren  Verriicktheit. 
Arch.  f.  Psych.,  Bd.  i. 


PARANOIA  569 

fabulation  and  dream-like  revery.  In  the  acme  of  the  disease 
these  individuals,  on  account  of  the  character  of  their  insane 
ideas,  are  classed  among  the  most  dangerous  lunatics.  Other 
observers  think  that  the  clinical  course  of  the  disease  is  one 
in  which  periods  of  vivid  hallucinosis  occur.  The  character 
of  the  fallacious  sense  perception  determines  the  mood  until 
eventually  mental  deterioration  develops.  The  symptomatic 
features  of  these  cases  were  considered  by  Neisser  to  be  a 
varied  combination  of  fallacious  sense  perceptions  with  an 
elaboration  of  the  ideas,  particularly  those  relating  to  the  per- 
sonality, and  in  the  second  place  an  excessive  tendency  towards 
the  falsification  of  memory.  A  number  of  writers,  particularly 
Meynert,  were  inclined  to  believe  that  such  individuals  had 
been  the  subjects  of  insane  ideas  for  the  greater  part  of  their 
lives.  Other  clinicians  have  endeavored  to  find  points  of  dif- 
ferential importance  between  this  and  other  forms  in  the 
manner  of  the  development  of  the  malady. 

The  importance  of  periods  of  hallucinosis  has  been  vari- 
ously estimated,  some  writers  holding  that  they  are  more  or 
less  constant,  others  that  they  are  only  occasional  and  episodic. 
Kraepelin,  in  the  last  edition  of  his  book,  dissents  from  the 
view  that  it  is  possible  to  trace  the  genesis  of  the  insane  idea 
back  to  an  early  period  in  youth,  but  thinks  that  the  so-called 
original  paranoiics  in  whom  the  disease  is  said  to  have  begun 
at  an  early  period  of  life  with  a  progressive  development, 
broken  by  acute  periods  or  exacerbations  with  marked  hallu- 
cinosis, should  be  classified  among  the  hebephrenics. 

One  of  Schott's  4  patients  has  been  under  medical  sur- 
veillance for  twenty-five  years.  On  account  of  the  detailed 
history  given  the  case  is  one  of  considerable  importance  in 
throwing  light  upon  certain  disputed  points  in  the  pathogenesis 
of  this  and  similar  conditions.  Prior  to  the  period  at  which 
this  patient  entered  the  asylum  in  1879  marked  eccentricities 


*  Schott,  A. :  Beitrag  zur  Lehre  von  der  sogenannten  originaren 
Paranoia.  Monatsschr.  f.  Psych,  u.  Neurol.,  1904,  Mai,  Bd.  xv,  H.  5, 
S.  321. 


S7o 


PSYCHIATRY 


of  character  had  already  been  noted  and  a  more  or  less  indefi- 
nite history  of  the  occurrence  of  insane  ideas,  even  in  earliest 
childhood,  was  given.  The  evidence  upon  this  latter  point, 
however,  is  believed  by  Schott  to  be  too  uncertain  to  justify 
its  recognition.  While  the  patient  was  under  observation 
periods  of  definite  hallucinosis  occurred.  In  1891  the  patient 
began  to  show  signs  of  megalomania,  and  the  ideas  which  then 
presented  themselves  persisted  with  remarkable  stability.  Al- 
though the  systematization  and  persistence  of  the  insane  ideas, 
together  with  a  certain  degree  of  intactness  of  memory  and 
the  power  of  intellectual  effort,  are  still  noted,  the  occurrence 
of  disturbances  in  the  motor  functions  during  the  attack  would 
naturally  suggest  the  idea  that  the  case  is  one  of  hebephrenia 
and  not  true  paranoia.  Schott  himself  is  of  the  opinion  that 
the  form  of  alienation  is  to  be  regarded  as  a  chronic  hallu- 
cinatory paranoia. 

In  the  careful  scrutiny  and  analysis  of  symptoms  the  clini- 
cian should  avoid  the  error  of  assuming  that  the  presence  or 
absence  of  slight  mental  deterioration  without  other  specific 
symptoms  can  be  accepted  as  a  means  of  differentiating  between 
?he  typical  cases  of  paranoia  and  other  forms  of  alienation.  As 
has  been  pointed  out  in  Chapter  III,  it  is  more  than  probable 
that  in  every  case  in  which  an  insane  idea  develops  a  certain 
amount  of  mental  impairment  exists.  Frequently  in  the  clinics 
individuals  are  met  with  who  show  a  series  of  stable  systema- 
tized insane  ideas  while  still  retaining  considerable  ability  in 
reasoning,  and  in  whom  there  can  be  noted  but  little  inter- 
ference in  the  volitional  processes  except  when  a  certain  line 
of  conduct  brings  these  into  conflict  with  their  delusions.  The 
history  of  such  individuals  is  that  gradually,  over  a  period  of 
years,  they  become  more  or  less  nervous  and  irritable  and 
nearly  always  show  a  tendency  to  be  more  and  more  self- 
centred.  This  latter  phenomenon  generally  shows  itself  in  a 
certain  degree  of  distrust  and  inability  to  adapt  themselves  to 
their  surroundings;  they  fail  to  get  along  with  friends  or 
relatives  and  begin  to  display  a  certain  queerness  and  eccen- 
tricity of  manner  which  is  sooner  or  later  recognized  as  ab- 


LITIGIOUS    INSANITY  571 

normal  even  by  the  laity.  Frequently  the  friends  will  tell  us 
that  these  individuals  have  always  been  queer,  have  always 
shown  marked  eccentricities  of  character,  have  always  been 
easily  prejudiced  and  possessed  by  fixed  ideas.  Gradually  the 
insane  ideas  become  more  and  more  crystallized,  and,  as  a  rule, 
first  one  or  two  make  their  appearance,  and  later  others  de- 
velop secondarily.  In  tracing  the  evolution  of  the  symptoms 
it  may  be  found  that  what  could  at  first  properly  be  described 
as  irritability  later  becomes  mistrust  or  suspiciousness.  The 
conduct  of  those  about  them  is  misinterpreted ;  everything  that 
is  done,  according  to  these  patients,  is  directed  against  their 
welfare;  poison  is  put  into  their  food;  they  are  followed  on 
the  street ;  if  confined  in  an  institution,  they  complain  that  they 
have  been  illegally  committed  and  spend  their  days  brooding 
over  this  fact.  Frequently  symptoms  of  definite  hallucinations 
are  present,  and  although  the  individual  may  not  admit  that 
such  is  the  case,  if  carefully  observed  he  will  often  be  noticed 
apparently  listening  to  the  sound  of  voices,  his  lips  moving  as 
if  attempts  were  being  made  to  reply;  in  short,  his  conduct 
will  in  many  ways  justify  the  belief  that  he  is  influenced  by 
fallacious  sense  perceptions. 

Not  infrequently,  in  addition  to  the  auditory  hallucina- 
tions, visual  and  particularly  haptic  forms  seem  to  affect  the 
conduct.  As  a  rule,  associative  memory  is  to  some  extent 
impaired,  but  it  often  happens  that  memories  immediately  af- 
fecting the  life  of  the  individual  are  fairly  well  preserved, 
whereas  those  connected  with  his  relationship  to  those  about 
him  are  either  defective  or  falsified.  The  emotional  tone  of 
such  individuals  is  conditioned  largely  by  the  occurrence  of 
hallucinations,  being  either  one  of  suspicion  or  fear,  or  of 
aggressiveness,  according  to  the  nature  of  the  fallacious 
sense  perception.  The  higher  faculties  are  more  or  less  in- 
terfered with.  These  defects  become  more  apparent  when 
the  symptoms  of  the  patient  are  the  immediate  subject  of 
discussion. 

Litigious  Insanity. — Another  important  class  of  cases 
to  which  the  attention  of  alienists  was  especially  directed  by 


572 


PSYCHIATRY 


the  writings  of  Hitzig 5  is  the  so-called  litigious  insanity.  As 
a  rule,  these  individuals  are  characterized  by  the  remarkable 
pertinacity  with  which  they  adhere  to  their  ideas.  They  have 
a  singular  disregard  for  the  rights  of  others  with  whom  they 
are  brought  into  contact  and  seem  utterly  unable  to  appreciate 
that  a  question  may  have  two  sides.  All  they  seek  for  is 
to  establish  what  they  regard  as  their  own  rights  without 
any  deference  for  the  feelings  or  rights  of  others.  It  is  fre- 
quently very  difficult,  particularly  for  the  laity  or  for  physicians 
who  have  had  no  experience  in  psychiatry,  to  determine  the 
existence  of  a  marked  mental  defect  in  these  individuals.  They 
are  generally  regarded  by  members  of  the  community  as  lim- 
ited in  their  interests,  excessively  egotistical,  and  stubborn; 
but  apart  from  these  apparent  eccentricities  of  character  they 
are  considered  normal.  The  more  one  is  brought  into  contact 
with  them  the  narrower  does  their  range  of  interest  appear. 
Their  conversation  is  limited  to  a  perpetual  harping  upon  af- 
fairs which  are  of  immediate  interest  only  to  themselves,  and 
in  action  as  well  as  in  word  they  show  an  utter  lack  of  the 
power  of  dissociating  themselves  from  the  very  small  world 
in  which  they  live.  As  a  rule,  they  have  an  exaggerated  sense 
of  self-consciousness  and  egotism.  Whatever  goes  on  about 
them  is  immediately  supposed  by  them  to  have  some  relation 
either  to  their  conduct  or  to  matters  which  pertain  to  them- 
selves. Generally  the  mental  disturbance  first  makes  its  ap- 
pearance in  connection  with  some  real  or  fancied  grievance, 
which  they  harbor  in  their  minds  and  brood  over  continuously. 
They  are  unable  to  recognize  that  other  persons  may  have 
rights,  and  their  own  individuality  is  the  centre  of  the  world 
in  which  they  live.  They  are  utterly  uncompromising  in  their 
actions  as  well  as  in  the  expression  of  their  own  individual 
opinions,  and  brook  no  interference.  An  opposing  opinion 
seems  to  stimulate  them  to  greater  obstinacy  and  make  their 

5  Hitzig :  Ueber  den  Querulantenwahnsinn,  1895.  Pfister :  Ueber 
Paranoia  chronica  querulatoria.  Allgem.  Ztschr.  f.  Psych.,  lix,  p.  589.  See 
also  Lane,  E.  B. :  Litigious  Insanity  with  Report  of  a  Case.  Am.  Journ. 
Insan.,  vol.  lix,  No.  2,  1902. 


LITIGiOUS    INSANITY 


573 


argumentative  aggressiveness  even  more  noticeable  and  more 
unpleasant.  Any  attempt  to  hold  them  back  merely  drives 
them  to  even  greater  lengths  in  attempting  to  establish  their 
fancied  rights.  Their  time  is  often  spent  in  writing  lengthy 
appeals  to  friends  or  officials  and  in  setting  forth  their  side 
of  the  case  with  the  greatest  minuteness  of  detail,  and  without 
admitting  in  any  way  that  the  person  with  whom  they  have 
been  brought  into  controversy  can  possibly  have  any  rights 
in  the  matter.  Persons  affected  by  forms  of  litigious  insanity 
are  great  nuisances  to  the  community.  A  failure  to  convince 
one  set  of  officials  of  the  merits  of  their  case  only  serves  to 
increase  their  pertinacity;  they  become  even  more  set  in  their 
determination  to  establish  their  claims,  and  immediately  go 
to  others  in  authority,  reiterating  their  grievances  and  clamor- 
ing for  justice.  As  the  mental  symptoms  in  these  cases  usually 
become  pronounced  during  the  prime  of  life  and  develop  in- 
sidiously, a  great  deal  of  annoyance  is  often  suffered  by  mem- 
bers of  their  family  and  friends  before  the  fact  is  recognized 
that  these  individuals  are  really  insane.  Not  infrequently  they 
are  conspicuous  litigants  in  the  courts,  and,  as  the  mental  de- 
terioration is  not  a  prominent  symptom,  their  supposed  griev- 
ances often  excite  the  sympathy  and  compassion  of  those  who 
are  unacquainted  with  all  the  facts. 

Gradually,  as  the  disorder  progresses,  the  argumentative- 
ness and  aggressiveness  become  so  intense  as  to  estrange  the 
individual  from  members  of  his  own  family.  Even  at  this 
stage  the  intellectual  capacity,  although  limited  in  certain  di- 
rections, may  be  retained  to  such  a  degree  that  there  may  be 
little  or  no  evidence  of  deterioration  that  can  be  appreciated 
by  those  who  are  not  experts.  Frequently  the  litigious  para- 
noiic,  if  he  has  failed  to  accomplish  his  ends  by  fair  methods 
and  by  legal  procedures,  will  adopt  foul  means,  contriving  all 
sorts  of  plots,  often  most  ingeniously  constructed,  and  some- 
times in  this  way  securing  the  aid  of  innocent  persons  in  the 
perpetration  of  some  crime.  Cases  are  on  record  in  which 
individuals  who  were  under  the  delusion  that  they  had  suf- 
fered the  loss  of  funds  through  the  action  of  friends  either 


574  PSYCHIATRY 

themselves  perpetrated  thefts,  or  incited  others  to  do  so  in 
order  to  acquire  the  money  which,  as  they  claimed,  had  been 
lost  or  had  been  taken  from  them  by  legal  procedures.  These 
patients  will  not  stop  short  of  any  means  to  accomplish  their 
ends,  and  even  deliberate  murders  not  so  very  rarely  have  to 
be  looked  upon  as  having  been  committed  by  individuals  suffer- 
ing from  this  form  of  insanity. 


CHAPTER    XXI 

THE    SENILE    GROUP.        PSYCHOSES     CONNECTED    WITH     THE 
PERIOD    OF    SENILE    INVOLUTION 

In  the  following  chapter  we  propose  to  give  an  account 
of  the  mental  disturbances  which  come  on  first  during  the  period 
of  senile  involution  and  are  not  recurrent  attacks  of  alienation 
that  have  appeared  prior  to  this  epoch  of  life.  In  order  to 
facilitate  the  discussion  of  these  disorders,  it  may  be  well  to 
refer  to  the  mental,  physical,  and  histological  changes  which 
are  characteristic  of  the  period  of  senescence.  The  mental 
changes  occurring  in  normal  old  age  are  in  a  measure  specific. 
It  may  be  said  in  a  general  way  that  there  is  marked  inter- 
ference with  the  synthetic  processes ;  in  other  words,  although 
the  critical  faculties  are  well  retained,  the  productivity  or 
mental  output,  as  compared  with  that  of  the  preceding  period 
in  life,  is  limited.  Of  course,  the  inference  is  not  to  be  drawn 
that  this  happens  in  all  cases,  for  history  contains  brilliant 
examples  of  remarkable  retention  of  intellectual  capacity,  even 
into  the  eighth  and  ninth  decades  (Virchow,  Gladstone).  But, 
generally  speaking,  the  acquisition  of  new  facts  and  intellectual 
expansion  in  the  normal  individual  do  not  continue  after  the 
fiftieth  year.  Not  only  does  this  enfeeblement  in  the  associa- 
tive mechanism  become  gradually  more  and  more  marked, 
but  there  is  also  a  narrowing  in  the  emotional  life..  In  ad- 
vancing years  the  individual  becomes  more  and  more  centred 
in  his  own  affairs  and  in  his  own  immediate  environment, 
so  that  only  with  considerable  difficulty  are  his  interests  ex- 
tended beyond  the  range  of  persons,  objects,  and  things  with 
which  he  has  long  been  familiar.  Associative  memory,  as  a 
rule,  is  one  of  the  first  functions  to  suffer.  Recent  impressions 
fade,  and  the  individual  shows  a  tendency  to  revert  more  and 
more  to  the  times  of  his  early  manhood  and  youth.  For  this 
reason,  as  a  rule,  there  is  an  apparent  indifference  and  lack 

575 


576  PSYCHIATRY 

of  interest  in  the  affairs  of  the  present,  and  the  "  good  old 
times"  are  referred  to  with  constantly  increasing-  frequency. 
As  may  be  inferred,  the  habits  and  customs  of  the  life  of  an 
individual  play  an  important  part  in  bringing  out  at  this  period 
eccentricities  of  character. 

The  bodily  manifestations  in  the  period  of  senescence  are 
very  varied  and  prominent.  Among  these,  as  a  rule,  are  the 
changes  in  the  facial  expression,  the  increase  in  the  number  of 
wrinkles  and  deepening  of  those  that  already  exist,  together 
with  a  general  wasting  of  the  musculature,  the  disappearance 
of  subcutaneous  fat,  and  considerable  impairment  in  the  motor 
activities.  The  senile  tremor  is  commonly  noted.  The  hair,  as 
a  rule,  is  white  and  sparse,  the  arcus  senilis  is  marked,  and  other 
senile  changes  in  the  eye  become  apparent.  In  some  instances 
the  pupils  are  uneven,  but  the  reactions  for  light  are  not,  as 
a  rule,  greatly  impaired  except  in  the  cases  which  suggest 
dementia  paralytica.  Various  neurotic  disturbances,  the  result 
of  arterial  changes,  are  also  noted,  while  imperfect  functioning 
of  the  heart,  liver,  and  other  organs  is  common. 

The  changes  that  occur  in  the  central  nervous  system  in 
senility  have  been  the  subject  of  considerable  investigation. 
Redlich  1  regards  all  the  changes  found  in  the  brains  of  indi- 
viduals who  have  died  at  an  advanced  age  as  marks  of  senility. 
Nevertheless,  it  would  seem  far  better  to  use  the  term  not  as 
meaning  a  normal  aging,  but  in  a  pathological  sense,  and  to 
class  under  this  category  only  those  alterations  which  do  not 
occur  in  the  majority  of  old  people. 

Chief  among  the  changes  in  the  brain  is  the  marked  de- 
crease in  its  weight,  as  shown  by  the  following  statistics  of 
Parchappe : 

30-39  yrs.  60-69  yrs. 

Man    1413  grm.  1334  grm. 

Woman    1246  1175 


1  Redlich,  E. :  Beitrag  zur  Kenntniss  der  pathologischen  Anatomie  der 
Paralysis  agitans  und  deren  Beziehungen  zu  gewissen  Nervenkrankheiten 
des  Greisenalters.  Arbeiten  aus  d.  Inst.  f.  Anat.  u.  Physiol,  d.  Nerven- 
systems.     H.  Obersteiner,  Wien,  1894. 


SENILE  PSYCHOSES  577 

In  nearly  all  cases  of  advanced  senility  there  is  also  consid- 
erable atrophy  of  the  convolutions,  with  a  deepening  and  broad- 
ening of  the  fissures.  In  the  interior  of  the  brain  we  meet  with 
a  dilatation  of  the  ventricles  and  canals  and  a  mild  grade  of  se- 
nile-hydrocephalus. In  the  cortex  we  not  infrequently  meet  with 
the  etat  crible  and  in  the  central  ganglia  the  foyers  lacunaires 
de  disintegration  described  by  Marie.  Accompanying  these 
gross  lesions  are  changes  in  the  nerve-cell,  a  granular  degen- 
eration of  the  Nissl  bodies,  with  a  chromatolysis.  In  many  of 
the  cells  there  is  a  marked  increase  in  the  pigmentation,  inter- 
preted by  some  authors  as  pigment  degeneration  of  the  cells. 

In  the  vascular  system  we  meet  with  dilatation  of  the  ves- 
sels, particularly  of  the  intra-  and  extra-adventitial  spaces 
(spaces  of  Virchow-Robin  and  His),  with  considerable  pig- 
mentation in  the  adventitial  coat.  The  neuroglia  is  usually 
increased  in  quantity,  both  the  cells  and  the  fibres,  but  particu- 
larly the  latter,  participating  in  the  process.  Colloid  degener- 
ation of  the  vessels  has  been  noted  by  Alzheimer,  and  its  oc- 
currence is  said  not  to  be  always  indicative  of  a  pathological 
lesion.  Associated  with  the  over-development  of  the  neuroglia 
tissue  there  is  an  increase  in  the  number  of  amyloid  bodies,  the 
origin  of  which,  according  to  Obersteiner,  is  probably  in  round 
yellow  bodies  found  in  the  glia-cells. 

In  a  certain  number  of  individuals  the  physical  changes 
incident  to  old  age  are  associated  with  marked  symptoms  of 
mental  aberration  during  life,  the  clinical  picture  as  well  as 
the  post-mortem  alterations  supplying  evidence  of  pathological 
lesions  in  the  central  nervous  system.  The  senile  psychoses 
may,  from  a  pathological  stand-point,  be  divided  into  three 
classes  :  ( 1 )  Cases  of  simple  senile  mental  disturbances,  dur- 
ing which  no  evidence  of  marked  organic  lesions  are  to  be 
found.  In  patients  dying  of  some  intercurrent  malady  and 
coming  to  autopsy  the  only  pathological  change  which  bears 
any  relation  to  the  alienation  is  a  very  slight  accentuation  o£ 
the  senescent  changes  already  described.  (2)  Cases  in  which 
the  symptoms  point  to  the  existence  of  definite  organic  lesions 
in  the  central  nervous  system  and  which  in  many  instances,  in 

37 


578  PSYCHIATRY 

the  clinical  picture  as  well  as  in  the  post-mortem  findings, 
simulate  cases  of  general  paresis.     (3)  The  senile  dementias. 

Besides  the  fact  that  this  grouping  is  very  convenient,  it 
offers  the  possibility  of  a  classification  upon  a  clinical  as  well 
as  a  pathological  basis.2  But,  nevertheless,  it  must  always  be 
borne  in  mind  that  the  cases  can  not  always  be  sharply  differ- 
entiated, and  the  groups  may  merge  into  each  other.  In  order 
not  to  repeat  what  has  already  been  said  in  Chapter  XV  upon 
the  subject  of  the  clinical  and  pathological  differentiation  be- 
tween the  atypical  cases  of  dementia  paralytica  and  certain 
forms  of  the  senile  psychoses,  only  two  clinical  groups,  corre- 
sponding to  (1)  and  (3),  will  be  discussed  in  the  present 
chapter. 

(1)  The  first  group  includes  states  of  (a)  mental  depres- 
sion, (b)  excitement.  Under  the  former  are  included  the  cases 
which  are  characterized  by  mental  depression,  generally  asso- 
ciated with  some  anxiety  and  apprehensiveness,  but  which  do 
not  form  a  part  of  other  psychoses.3  These  cases  are  among 
the  most  common  of  all  the  forms  of  alienation  which  develop 
at  this  period  of  life.  The  duration  of  the  disease  varies  from 
several  weeks  to  one  or  two  years,  and  in  a  large  percentage  of 
the  cases  there  is  an  ultimate  recovery.  The  onset,  as  a  rule, 
is  insidious  and  slowly  progressive.  In  the  majority  of  cases 
there  is  at  first  a  slight  accentuation  of  the  senile  mental 
changes  to  which  reference  has  already  been  made;  but  after 
some  one  of  various  exciting  causes  has  intervened,  the  patient 
shows  a  tendency  to  become  more  and  more  egocentric.  The 
outside  world  contains  less  of  interest  for  him  and  he  becomes 
absorbed  entirely  in  his  own  immediate  environment.  The 
initial  symptoms  as  well  as  the  later  stages  of  the  disease  have 
a  strong  individualistic  stamp.  Personal  idiosyncrasies  are 
accentuated,  and  the  patient  becomes  hypochondriacal,  more 
or  less  indifferent,  or  introspective,   in  accordance  with  the 


2  Cramer,    A.:     Die    senile    Seelenstorung.      Patholog.    Anatomie    des 
Nervensystems,  1904,  Bd.  ii,  S.  1504. 

8  Kraepelin  :    Psychiatrie,  Siebente  Auflage. 


PLATE  XX 


Senile  melancholia. 


SENILE    PSYCHOSES 


579 


traits  of  character  exhibited  during  his  former  life.  Not  only 
do  the  personal  qualities  become  exaggerated  in  the  early  stages 
of  the  disease,  but  the  daily  life  of  the  individual,  to  which  he 
has  become  accustomed  for  years,  becomes  reflected  in  this 
stage.  Thus,  the  business  man  first  loses  pleasure  and  interest 
in  his  daily  occupation  and  begins  to  worry  about  trifles.  He 
is  easily  confused,  complains  that  every  mental  effort  causes 
him  too  great  an  output  of  energy,  every  new  undertaking 
immediately  gives  rise  to  apprehensiveness,  and  the  fear  of 
failure  may  be  so  great  as  to  cause  marked  emotional  disturb- 
ances. Early  in  the  disease,  as  a  rule,  the  subjective  feeling 
of  insufficiency  develops ;  in  fact,  this  is  one  of  the  most  char- 
acteristic symptoms  of  the  disease  and  plays  an  important  part 
in  its  further  development.  This  sensation  varies  in  intensity 
from  one  of  mere  dejection  to  a  feeling  of  anguish,  and  when 
unassociated  with  the  fixed  ideas  is  in  a  measure  proportional 
to  the  intrapsychic  akinesis.  As  the  disease  progresses  the 
akinetic  disturbances  become  more  and  more  marked,  until 
finally  they  are  evident  in  the  impairment  of  connected  thought 
as  well  as  in  the  diminution  in  extent  and  energy  of  all  voli- 
tional movements.  The  mental  inertness  is  shown  in  a  great 
variety  of  ways,  and  may  in  part  be  attributed  to  the  alteration 
in  those  psychic  sensations  which  are  so  immediately  depend- 
ent upon  the  general  organic  sensations.4  That  series  of  com- 
plex affective  states  which  we  refer  to  commonly  as  pleasure, 
love,  hate,  and  so  forth,  is  in  the  ultimate  analysis  dependent 
upon  the  preservation  of  the  normal  organic  sensations,  and 
when  there  is  any  interference  with  these,  there  is  a  correspond- 
ing change  in  the  emotional  reactions.  For  this  reason  the 
progressive  feeling  of  insufficiency  and  depression  is  accom- 
panied by  a  corresponding  decrease  in  the  number  of  emotional 
reactions,  a  deficiency  that  becomes  more  apparent  the  more 
highly  organized  and  sensitive  the  character  of  the  patient 
prior  to  the  attack. 

Although  there  is  a  diminution  in  some  of  the  organic  sen- 

4  Wernicke.     Op.  cit,  345. 


580  PSYCHIATRY 

sations,  others  become  intensely  exaggerated,  and  these  un- 
doubtedly form  the  basis  upon  which  many  of  the  hypochon- 
driacal states  develop.  In  many  cases  the  patient  becomes  more 
or  less  rapidly  self-centred,  evincing  little  or  no  interest  even 
in  the  immediate  members  of  the  family,  so  occupied  is  he 
by  his  own  symptoms  and  the  course  of  the  disease.  In  the 
hypochondriacal  form  the  individual  frequently  affirms  that 
the  disease  with  which  he  is  afflicted  is  incurable  and  that 
medical  aid  can  be  of  no  avail.  The  deepening  mental  gloom 
is  broken  only  by  renewed  expressions  of  hopelessness  and 
dismal  laments  regarding  his  poor  physical  condition.  In 
some  instances  the  patient's  attention  is  mainly  centred  in  his 
thoracic  or  abdominal  organs,  and  he  not  uncommonly  affirms 
that  his  viscera  have  been  transposed,  injured,  or  even  removed. 
A  good  example  of  these  delusions  is  afforded  by  the  following 
case: 

Male,  aged  63,  married.  Admitted  to  the  Sheppard  and  Enoch  Pratt 
Hospital  June  27,  1901. 

Family  History. — One  sister  insane. 

Personal  History. — The  patient  has  had  no  illness  since  childhood 
except  occasional  attacks  of  indigestion.  Has  never  used  tobacco  nor 
alcohol.  Has  been  married  35  years ;  his  wife  and  several  children  are 
living.  While  he  has  always  done  hard  mental  work  he  has  had  no  nervous 
breakdown. 

Present  Illness. — In  the  summer  of  1900  the  patient  became  greatly 
worried  about  his  work,  and  by  October  had  become  extremely  nervous. 
He  was  troubled  with  insomnia  and  was  in  a  state  of  continued  depression, 
which  increased  to  absolute  hopelessness  about  himself.  He  had  fixed 
ideas  relating  exclusively  to  his  own  person.  He  thought  that  his  food 
was  not  being  properly  assimilated,  and,  although  his  appetite  was  good, 
he  constantly  affirmed  that  he  had  no  desire  to  eat.  In  December  he 
expressed  the  fear  that  he  was  losing  his  mind  and  would  not  be  able  to 
attend  to  his  daily  occupation.  In  January,  1901,  the  patient  weighed  75 
pounds,  a  loss  of  50  pounds  from  his  normal.  He  complained  of  a  throb- 
bing sensation  in  his  brain  and  of  increasing  worry  concerning  his  digestive 
troubles.  He  soon  felt  obliged  to  give  up  his  work  and  went  to  an  institu- 
tion for  treatment.  The  insomnia  and  mental  depression  increased.  He 
had  the  fixed  idea  that  his  digestive  organs  were  drying  up,  that  his  body 
was  disintegrating,  and  that  to  take  food  would  be, fatal.  These  symptoms 
continued  pretty  much  the  same  until  June,  when  he  expressed  his  inten- 
tion of  starving  himself  to  death  and  thus  ending  his  suffering. 

Present  Condition. — On  admission  the  following  note  was  made :    The 


SENILE    PSYCHOSES  581 

patient  remains  in  bed,  makes  no  effort  to  assist  himself,  and  relies  entirely 
upon  the  nurse.  The  facial  expression  is  fixed  and  indicates  a  depressed 
mood.  There  are  horizontal  furrows  on  the  forehead  and  two  slight  per- 
pendicular grooves  between  the  eyes.  He  shows  no  marked  aversion  to 
talk  and  answers  questions,  but  is  markedly  egocentric  and  convinced  of 
the  truth  of  the  ideas  regarding  his  physical  and  mental  condition.  He 
affirms  that  his  present  condition  is  due  to  overwork  and  insomnia  and 
that  the  latter  has  led  to  insanity.  He  says  that  prior  to  the  onset  of  the 
disease  his  organs  functioned  normally,  but  now  their  action  has  become 
vitiated  and  everything  about  his  physical  economy  has  gone  wrong.  He 
is  not  self-accusatory,  but  is  constantly  brooding  over  his  condition,  mani- 
festing many  and  varied  hypochondriacal  symptoms.  He  says  that  he  has 
no  appetite  and  does  not  wish  to  eat,  that  everything  tastes  alike,  and 
that  when  his  eyes  are  closed  he  can  not  tell  one  article  of  food  from 
another.  He  declares  that  every  mouthful  he  takes,  instead  of  digesting, 
remains  inside  of  him  and  ferments,  and  that  his  bowels  are  never  moved 
naturally.  Speech  is  slow  and  somewhat  hesitating;  the  tone  of  the  voice 
is  low,  with  falling  cadences.  There  are  no  aphasic  symptoms.  He  de- 
clares that  his  hearing  is  failing;  that  he  is  unable  to  recognize  familiar 
sounds.  He  has  shown  no  delusions  regarding  his  personality  and  has  not 
mistaken  the  identity  of  other  persons. 

Physically  he  is  anaemic  and  emaciated.     Tongue  clean  and  moist. 

Audition :  Hears  watch  at  a  distance  of  five  or  six  inches  from  the 
right  and  one  or  two  inches  from  the  left  ear. 

The  eyes  show  nothing  abnormal. 

The  tendon  reflexes  are  all  diminished.  Epigastric  active,  cremasteric 
fair. 

Heart  sounds  extremely  weak.  No  apex  beat  localized  on  inspection 
or  palpation. 

Blood :  Haemoglobin,  65  per  cent.  Red  blood-cells,  4,900,000 ;  leuco- 
cytes, 8000. 

Several  months  later  it  is  noted  that  the  patient's  mood  has  not  changed 
and  he  is  still  depressed  and  introspective.  He  has  had  some  slight  trouble 
with  his  nose  and  thinks  that  the  mucous  membrane  is  gone.  He  says  his 
nose  is  closing  up,  that  his  nasal  passages  will  soon  be  entirely  closed,  and 
that  he  will  be  unable  to  breathe  through  them.  December,  1901.  The 
somatic  delusions  persist.  Suspects  that  he  is  losing  his  speech.  Main- 
tains that  his  food  does  not  digest,  but  merely  piles  up  inside  of  him.  Has 
been  under  the  impression  that  the  respiratory  passages  are  becoming 
occluded.  He  does  not  cleanse  his  nostrils  properly  and  will  not  allow 
his  face  to  be  touched  while  being  bathed,  fearing  that  water  will  get  into 
his  nose  and  thus  suffocate  him. 

November,  1902.  Still  insistent  upon  the  "  disorganization  of  the  body, 
principally  the  intestinal  tract."  Does  not  initiate  conversation ;  remains 
seated  quietly ;  does  not  pay  any  attention  to  conversation  between  others ; 
watches  the  movements  of  patients  and  nurses,  but  does  not  enter  into  con- 
versation. Occasionally  walks  over  to  the  window  and  looks  out  at  the 
view.     The  improvement  during  1902  has  been  very  slow.     Patient  admits 


582  PSYCHIATRY 

that  he  sleeps  better  than  formerly,  although  he  still  maintains  some  of 
his  ideas  about  his  digestive  tract. 

As  in  this  case,  the  patients  seem  to  show  considerable 
appreciation  of  the  fact  that  they  are  the  subjects  of  mental 
aberration.  They  express  the  fear  that  they  are  losing  their 
minds,  and  in  proof  of  the  truth  of  their  declarations  refer 
to  the  mental  confusion,  vertigo,  and  other  abnormal  sensations 
with  which  they  are  affected. 

In  addition  to  the  hypochondriacal  feelings,  many  patients 
show  a  marked  tendency  to  brood  over  sins  of  omission  as 
well  as  of  commission  of  which  they  affirm  they  have  been 
guilty.  Utterly  disconsolate,  they  dwell  upon  acts  committed 
in  their  youth,  and  mere  peccadilloes  are  now  looked  upon  as 
heinous  offences.  They  remember  on  a  certain  occasion  having 
told  a  lie  and  affirm  that  the  memory  of  this  sin  has  persisted 
all  their  lives,  and  now  Providence  has  burned  its  imprint 
upon  the  brain  and  sent  the  disease  as  a  just  retribution.  Fre- 
quently the  observer  is  struck  by  the  fact  that  the  causes  as- 
signed by  the  patients  as  reasons  for  their  despondency  are 
wholly  insufficient  and  out  of  all  proportion  to  the  excessive 
affective  disorder.  In  addition  to  the  ideas  of  culpability  and 
criminality,  we  frequently  meet  with  those  of  persecution,  which 
are  very  apt  to  be  colored  by  the  emotional  tone  of  the  patient. 
Or,  again,  a  patient  may  affirm  that  life  has  been  too  happy, 
that  he  has  been  too  selfish,  and  has  lived  in  the  present,  taking 
no  thought  for  the  morrow;  that  as  the  result  of  this  frame 
of  mind  he  has  given  little  attention  to  matters  of  religion, 
and  consequently  God  wishes  to  direct  his  thoughts  to  less 
worldly  affairs,  and  so  torments  the  body  in  order  that  his  mind 
may  be  set  on  higher  things.  Not  infrequently  the  ideas  are 
associated  with  a  human  agency  and,  if  this  is  the  case,  the 
illness  is  regarded  as  the  result  of  poison  which  has  been  put 
into  his  food.  At  other  times  the  ideas  of  being  persecuted 
and  of  having  sinned  are  combined.  Patients  express  a  fear 
that  they  are  to  be  brought  before  a  court  of  justice  to  be  tried 
for  crimes,  and  in  spite  of  their  innocence  are  to  be  convicted. 


SENILE    PSYCHOSES  583 

They  are  firm  in  their  declaration  that  no  reason  exists  why 
this  calamity  should  overwhelm  them  and  they  be  cast  upon 
such  a  sea  of  trouble.  Life  has  become  a  hell  upon  earth,  owing 
to  the  supposed  faithlessness  of  family  and  friends,  and  they 
alone  and  unaided  must  wander  through  a  slough  of  despond. 
Not  infrequently  such  individuals  complain  of  great  annoy- 
ance from  being,  as  they  suppose,  under  continual  observation. 
Nothing  that  they  do  can  remain  hidden ;  their  acts  and  even 
their  thoughts  are  known  to  those  about  them;  they  long  for 
some  degree  of  privacy  and  dread  the  publicity  to  which  they 
think  they  are  exposed. 

In  many  cases  extreme  poverty  is  complained  of.  Even 
well-to-do  individuals  affirm  that  they  have  lost  every  cent; 
that,  as  a  result,  they  have  been  sent  to  what  was  represented 
to  them  as  a  hospital  but  is  in  reality  a  poor-house;  that  not 
only  they  but  their  family  and  friends  are  in  absolute  need; 
that  nobody  knows  of  this  fact  but  themselves,  and  that  noth- 
ing remains  for  them  but  to  die  before  the  disgrace  becomes 
public,  and  they  long  for  death  in  the  hope  that  the  misery  of 
seeing  relatives  and  friends  in  great  want  may  be  spared  to 
them.  Sometimes  patients  in  this  state  affirm  that  they  have 
accumulated  enormous  debts  which  can  not  be  paid,  and  this 
delinquency  may  be  referred  to  their  deficient  business  capacity 
or  to  the  improper  use  they  have  made  of  funds  entrusted  to 
their  care. 

In  some  instances  the  ideas  are  nihilistic  in  quality.  The 
whole  world  is  changed.  The  air  that  the  patients  breathe  is 
becoming  less;  the  food  supply  is  at  an  end;  there  is  no 
possible  help,  not  only  for  themselves,  but  for  those  about 
them.  All  are  dying  or  are  actually  dead,  and  they  alone 
survive.  Not  only  is  the  world  about  to  be  destroyed,  but 
the  whole  universe  is  rapidly  disappearing;  nothing  remains 
but  chaos.  The  following  extract  from  the  letter  of  a  patient 
illustrates  these  nihilistic  ideas  as  well  as  the  dissociation  of 
thought : 

"  Were  the  whole  world  mine  or  the  wealth  of  it,  I  would  give  it  for 
one  moment  of  life.    Dr.  X  said,  '  You  can  live  if  you  want'    Dr.  Y  said 


584  PSYCHIATRY 

put  her  at ,  but  time,  place,  position,  nor  people  can  have  effect  on  this 

that  was  not  allowed  what  the  smallest  insect  has  or  the  vilest  beast.  No 
heart  with  the  pulsations  of  life,  no  brain  with  a  sensation  of  feeling,  no 
body  to  ache  or"  decay,  but  when  an  infant  robbed  of  all  that  belongs  to 
mortals." 

In  a  comparatively  few  cases  we  find  that  the  individual 
has  the  idea  that  he  is  possessed  by  evil  spirits  or  that  he  is 
transformed.  On  account  of  the  awfulness  of  his  supposed 
crimes  he  has  been  turned  into  an  animal,  a  dog  or  a  cat,  and 
as  a  consequence  of  early  delinquencies  is  destined  to  an  un- 
broken metempsychosis. 

In  regard  to  the  genesis  of  the  insane  ideas  a  great  variety 
of  opinions  have  been  advanced  by  different  authors.  Heller  5 
maintains  that  in  the  uncomplicated  cases  they  are  an  attempt 
on  the  part  of  the  patient  to  interpret  the  abnormal  feelings 
that  depend  upon  the  disturbances  in  the  complex  of  organic 
sensations.  As  a  result  of  these  anomalies  the  patient  develops 
strange  ideas,  not  only  in  regard  to  his  own  personality,  physi- 
cally as  well  as  mentally,  but  also  to  his  relationship  with 
the  external  world.  From  the  former  spring  the  ideas  of  self- 
depreciation,  accusation,  and  hypochondriasis,  while  from  the 
latter  arise  those  ideas  of  reference  that  culminate  in  a  well- 
developed  belief  of  persecution,  etc.  The  same  author  believes 
that  the  development  of  the  insane  ideas  out  of  obsessions,  fal- 
lacious sense  perceptions,  and  "  audible  thoughts"  indicates 
the  existence  of  a  complicating  psychosis.  According  to 
Ziehen,  the  hallucinations  are  met  with  in  about  one-tenth  of 
all  the  cases,  and  auditory  forms,  when  they  occur,  generally 
consist  of  elementary  sounds  localized  in  the  head,  chest,  or 
abdomen,  or  may  resemble  psychic  hallucinations.  Systema- 
tization  of  the  insane  ideas  is  not  at  all  infrequent,  and  is  par- 
ticularly noticeable  at  the  height  of  the  disease.  Schott 6  has 
affirmed  that  its  presence  does  not  by  any  means  justify  the 


Heller:    Die  Wahnideen  der  Melancholiker.     Inaug.  Diss.,  Marburg, 


1! 


6  Schott :    Beitrag  zur  Lehre  von  der  Melancholie,  Arch.  f.  Psych,  u. 
Nervenkrankh.,  Bd.  xxxvi,  H.  3. 


SENILE   PSYCHOSES  585 

statement  that  the  prognosis  is  unfavorable.  In  the  cases 
where  the  mental  depression  is  the  dominating  feature  the 
facial  expression  is  essentially  characteristic.  As  a  rule,  the 
skin  over  the  forehead  is  wrinkled,  owing  to  contraction  of 
the  frontalis  muscle.  The  wrinkles  are  horizontal,  except  just 
between  the  two  eyes,  where  frequently  there  are  several  short 
perpendicular  furrows.  When  the  anxiety  and  apprehensive- 
ness  are  not  great,  the  corners  of  the  mouth  are  usually  de- 
pressed, the  lips  tightly  closed,  the  eyes  often  have  a  glassy 
and  vacant  look.  The  attention  of  these  patients  varies  some- 
what with  the  degree  of  depression.  In  the  milder  cases  it 
is  easily  gained,  but  retained  with  difficulty,  as  the  patient 
constantly  tends  to  revert  to  himself  and  his  complaints.  Asso- 
ciative memory  is  not  apt  to  be  greatly  impaired  except  in 
so  far  as  it  is  affected  by  the  depression  and  insane  ideas,  to 
which  reference  has  already  been  made.  Frequently  the  pa- 
tients are  well  oriented  for  time  and  place,  and,  except  in  the 
very  severe  forms,  there  is  no  marked  disturbance  in  con- 
sciousness. In  a  comparatively  large  number  of  the  cases 
the  emotional  disturbances  play  a  very  important  part,  and 
chief  among  these  is  the  state  characterized  by  great  anxiety 
and  apprehensiveness — the  Angst  of  the  Germans. 

Although  it  is  not  improbable  that  cases  of  mental  de- 
pression with  marked  apprehensiveness  and  anxiety  may  de- 
velop relatively  early,  it  cannot  be  denied  that  the  majority 
are  first  noted  after  the  prime  of  life  has  passed.  The  appre- 
hensiveness may  at  first  be  definitely  localized  in  the  chest  or 
abdominal  cavity  or  even  more  sharply  limited  to  the  precordial 
region.  The  dependence  of  this  symptom  upon  cardiac  lesions 
has  already  been  referred  to  in  the  chapter  on  Anomalies  of 
Emotion.  Unquestionably,  in  many  cases  the  mental  symp- 
toms already  referred  to  are  complicated  by  the  appearance 
of  periods  of  great  anxiety  and  apprehensiveness.  The  pri- 
mary sensation,  as  has  been  stated,  may  at  first  be  localized, 
but  rapidly  becomes  more  general,  and  not  only  intensifies 
the  depression  and  furnishes  a  new  basis  for  the  further  de- 
velopment of  the  insane  ideas,  but  is  also  reflexly  affected  by 


586  PSYCHIATRY 

the  presence  of  other  symptoms.  When  the  apprehensive- 
ness  is  marked,  the  motor  restlessness,  as  a  rule,  becomes  very 
great.  Such  patients  pull  at  their  clothes,  scratch  themselves, 
bite  their  fingers,  wander  aimlessly  about  the  wards,  complain 
of  a  great  variety  of  indefinite  fears,  and  act  as  if  they  were 
under  the  shadow  of  some  impending  evil,  concerning  the  na- 
ture of  which  they  have  only  a  faint  inkling.  Frequently  they 
barely  have  time  to  give  expression  to  one  fear  before  this  idea 
seems  to  be  forgotten  and  a  new  one  takes  its  place  in  con- 
sciousness. In  some  cases  the  apprehensiveness  is  associated 
with  hypochondriacal  ideas,  while  in  others  those  of  self-abase- 
ment, of  persecution,  and  the  other  forms  already  mentioned 
frequently  make  their  appearance  and  exert  a  dominating  in- 
fluence on  the  patient.  The  history  of  the  following  case 
shows  clearly  the  genesis  of  some  of  the  symptoms  and  is  in 
many  respects  characteristic: 

Male,  aged  52.    Farmer. 

Family  History. — Father  died  of  "  cardiac  dropsy."  Mother  died  at 
68  of  heart  trouble.     No  nervous  or  mental  disease. 

Personal  History. — Ordinary  diseases  of  childhood.  Sunstroke  at  the 
age  of  32.  Very  severe  attack.  Unconscious  for  two  and  a  half  hours. 
Convalescence  slow.  Typhoid  fever  three  years  ago.  Very  delirious 
during  the  attack.  Influenza  last  winter  followed  by  heart  trouble.  The 
patient  has  always  been  rather  excitable  and  slightly  impulsive.  Other- 
wise no  anomalies  of  character.  Steady  worker.  No  history  of  alcohol  or 
narcotics.     No  venereal  disease. 

Present  Illness. — Following  the  attack  of  grippe  last  winter  the  patient 
began  to  brood  a  good  deal  over  his  ailments.  For  two  or  three  months  he 
had  periods  of  mental  depression,  occurring  about  once  a  week,  which 
gradually  increased  in  frequency  until  they  recurred  every  day.  For  a 
month  prior  to  admission  to  the  hospital  he  had  shown  symptoms  of  motor 
restlessness  and  would  tear  his  clothes  and  hair,  pray  in  a  loud  tone  of 
voice,  sing,  etc.  The  excitement  was  most  marked  during  the  afternoon 
and  night.  The  patient  declared  that  he  was  ruptured,  had  spinal  trouble, 
that  people  were  cutting  holes  in  the  back  of  his  neck,  that  he  had  dropsy 
and  other  bodily  ills.  At  times  he  affirmed  that  he  himself  was  to  blame 
for  these  injuries  and  would  repeat  for  hours  at  a  time,  "  Why  did  I  do 
that?"  Since  the  attack  began  he  has  been  unable  to  write.  The  day  he 
was  admitted  to  the  hospital  he  tried  to  sign  a  cheque  for  his  wife  but 
could  not  do  it.  Although  greatly  excited  during  the  last  month  he  has 
shown  considerable  appreciation  of  his  mental  condition  and  referred  fre- 
quently to  the  fact  that  he  was  going  to  the  hospital.    Just  prior  to  admis- 


SENILE    PSYCHOSES  587 

sion  to  the  hospital  he  shot  at  his  wife  and  then  attempted  to  commit 
suicide. 

Physical  Examination. — October  31.  Patient  lying  in  bed  on  his  back. 
On  the  approach  of  the  examiner  he  glares  at  him  in  a  wild  way,  but  almost 
immediately  turns  his  eyes  away.  Well  nourished,  muscular  development 
good.  No  excess  of  fat.  At  times  shows  no  tendency  to  change  posture  of 
body  in  bed,  retaining  uncomfortable  position  for  several  minutes.  Occa- 
sionally he  moves  the  bedclothes  and  looks  under  them  as  if  he  were  seek- 
ing for  something,  and  then  begins  to  pick  at  the  skin  over  the  abdomen 
as  if  there  were  some  paresthesia.  At  intervals  of  two  or  three  minutes  he 
starts  up  as  if  he  were  actuated  by  sudden  impulses.  His  expression  at 
this  time  is  one  of  anxiety  and  apprehensiveness,  and  he  almost  imme- 
diately lapses  into  his  former  slightly  apathetic  state.  Noises  made  by 
tapping  on  the  bed  or  the  tick  of  a  watch  held  close  to  his  ear  seem  to 
make  little  if  any  impression  upon  him.  Occasionally  he  looks  in  the  direc- 
tion of  the  person  addressing  him.  The  majority  of  his  volitional  reactions 
do  not  seem  to  be  the  result  of  external  stimulation,  with  the  possible  ex- 
ception that  he  occasionally  promptly  shows  some  resentment  on  being 
touched,  but  the  repetition  of  this  stimulation  fails  to  induce  similar  results. 
The  sound  of  voices  makes  little  if  any  impression.  He  does  not  attempt 
to  answer  questions.  At  one  time  he  smacked  his  lips  as  if  he  wanted  to 
drink,  but  when  water  was  brought  to  him  he  made  no  attempt  to  help 
himself.  Occasionally  he  seems  to  be  bothered  by  flies  and  makes  an 
attempt  to  catch  them.  When  the  mouth  is  forcibly  opened  by  a  spoon  or  a 
tongue-depressor  no  gagging  follows,  but  as  soon  as  the  spoon  is  with- 
drawn the  patient  rapidly  protrudes  and  retracts  the  tongue.  These  move- 
ments are  kept  up  for  several  seconds.  The  eyes  show  nothing  abnormal 
beyond  injection  of  the  corneal  vessels  and  a  very  slight  irregularity  of  the 
left  pupil. 

Heart :  Cardiac  dulness  begins  at  the  third  interspace,  extends  beyond 
the  nipple  to  P.  M.  I.,  which  is  located  with  the  stethoscope  in  the  fifth 
interspace  outside  the  nipple.  The  heart's  action  shows  marked  irregu- 
larity, noticeable  at  the  apex  as  well  as  in  the  radial  pulse.  Five  or  six 
beats  in  rapid  succession  are  followed  by  two  or  three  slow  ones  separated 
by  long  intervals.  There  is  a  systolic  murmur  at  the  apex.  The  second 
sound  is  snapping  in  character.  In  the  pulmonic  area  the  first  sound  is 
murmurish.  The  second  sound  is  stronger.  Lungs  normal  on  auscultation 
and  percussion. 

Reflexes:  Knee-jerks  exaggerated.  Cremasteric  reflexes  present. 
Neither  McCarthy's  reflexes  nor  the  abdominal  skin  reflexes  obtained. 
Dermatographia  is  slow  in  appearing.  No  rigidity  on  passive  movement. 
No  paralyses. 

Four  days  after  admission  a  slight  improvement  was  noted.  The 
patient  apprehended  and  answered  some  questions.  At  night  he  was  very 
much  disturbed.  He  spent  a  good  deal  of  his  time  praying  that  he  might 
die  and  go  to  Heaven.  For  the  next  ten  days  the  patient  was  in  a  state 
characterized  by  great  apprehensiveness  and  anxiety.  He  moaned  and 
groaned  a  great  deal  of  the  time,  and  would  run  up  and  down  the  ward, 


588  PSYCHIATRY 

wringing  his  hands  and  crying  "  My  God !"  at  the  top  of  his  voice.  When 
spoken  to  sharply  he  would  reply  intelligently,  giving  his  age,  name,  and  so 
on,  but  almost  immediately  would  begin  to  ramble  again.  Blood-pressure, 
190  millimetres.  One  month  after  admission  there  was  marked  self-accusa- 
tion. No  psychomotor  retardation,  but  a  constant  expression  of  hypochon- 
driacal ideas.  He  began  to  show  some  slight  anxiety  about  his  family  and 
to  take  notice  of  the  objects  and  things  about  him.  Towards  the  end  of 
the  second  month  there  was  considerable  improvement.  He  appreciated  his 
condition — that  he  had  been  ill  and  that  he  was  recovering — although  the 
hypochondriacal  ideas  were  still  marked. 

The  urine  showed  nothing  abnormal.     Indican,  sulphates,  phosphates, 
and  chlorides  were  practically  normal.     No  albumin,  no  sugar. 

In  this  and  in  similar  cases  the  consciousness  is  much 
more  markedly  affected  than  in  the  pure  types  of  affective 
melancholia,  and  not  infrequently  associative  memory  is  also 
considerably  disturbed.  This  may,  in  a  measure,  be  dependent 
upon  the  fluctuations  of  the  attention,  which  seem  to  become 
more  noticeable  the  greater  the  anxiety  and  apprehensiveness. 
In  both  classes  of  cases,  as  may  be  inferred,  there  is  great  dan- 
ger of  the  patient  committing  suicide,  and  where  the  emotional 
disturbances  are  marked  the  attempt  may  be  made  to  inflict 
injury  upon  others.  These  patients  should  be  under  constant 
observation  and  never  left  alone.  As  a  rule,  from  the  begin- 
ning until  the  end  of  the  disease  insomnia  is  common,  and  even 
when  sleep  is  obtained  it  is  apt  to  be  restless  and  broken  by 
unpleasant  and  terrifying  dreams.  The  appetite  is  poor,  and 
forced  feeding  must  frequently  be  resorted  to. 

Gastro-intestinal  disturbances  and  obstinate  constipation 
are  common.  The  surface  temperature  is  not  infrequently 
lowered,  the  extremities  being  cool  and  sometimes  slightly 
cyanotic.  The  pulse,  as  may  be  inferred,  is  frequently  abnor- 
mal and  gives  evidence  of  the  presence  of  arterial  changes. 
The  pressure  is,  as  a  rule,  high.  Cardiac  lesions  are  common. 
The  skin  is  usually  dry  and  shows  evidence  of  nutritional 
changes. 

In  addition  to  the  physical  symptoms  already  noted,  in  at 
least  one-half  of  the  cases  there  is  a  marked  increase  in  the 
deep  reflexes.  In  a  comparatively  few  cases  a  diminution  is 
noted  which  often  is  associated  with  the  appearance  of  sugar 


SENILE    PSYCHOSES  589 

in  the  urine.  The  vasomotor  disturbances  are  frequently 
marked.  Dermatographia,  as  a  rule,  is  easily  obtained  and 
persists  for  a  considerable  length  of  time.  Schott  has  estimated 
that  in  at  least  12  per  cent,  of  the  cases  there  is  a  marked 
increase  in  the  mechanical  irritability  of  the  muscles,  particu- 
larly at  the  period  when  there  is  considerable  impairment  in 
the  nutrition.  The  disturbances  in  sensation  are  largely  psychic 
in  origin.  The  bodily  weight  falls  and  remains  low.  As  a 
rule,  the  rise  in  the  curve  is  the  first  indication  of  improve- 
ment. 

Course  and  Prognosis. — The  disease  pursues  a  chronic 
course,  varying  from  a  few  weeks  to  two  or  more  years.  In 
the  milder  cases  the  ups  and  downs  are  more  marked  than  in 
the  severer  forms,  in  which  the  mental  state  of  the  patient 
frequently  remains  stationary  for  long  periods  of  time.  As 
the  bodily  weight  increases  and  the  general  physical  condi- 
tion improves,  the  mental  symptoms  gradually  begin  to  dis- 
appear. The  systematization  becomes  less  marked.  The 
patients  express  doubt  as  to  the  truth  of  the  fixed  ideas  and 
are  willing  to  admit  that  their  mental  depression  as  well  as 
their  feeling  of  insufficiency  and  the  fixed  ideas  are  the  result 
of  physical  ailments.  Sometimes  a  period  characterized  by 
irritability  and  varying  degrees  of  motor  restlessness  inter- 
venes, and  associated  with  this  there  are  marked  fluctuations 
in  the  emotional  life.  Naturally  the  longer  the  duration  the 
more  unfavorable  is  the  prognosis,  but  cases  of  complete  re- 
covery have  been  reported  after  the  disease  had  lasted  for  four 
or  five  years.  As  a  rule,  the  tendency  for  the  insane  ideas  to 
become  systematized  is  more  marked  in  the  cases  which  begin 
at  a  very  advanced  period  of  life  than  in  the  earlier  ones. 

The  prognosis  in  a  large  number  of  cases  is  favorable. 
Kraepelin  reports  that  32  per  cent,  of  his  patients  recovered, 
while  in  23  per  cent,  a  marked  improvement  took  place.  Ac- 
cording to  Schott,7  there  was  a  complete  recovery  in  35.2 
per  cent,  of  the  cases  which  occurred  in  the  fifth  decade,  and 

7  Op.  cit. 


59° 


PSYCHIATRY 


in  22.2  per  cent,  of  those  which  came  on  during  the  sixth 
decade.  The  prognosis  becomes  more  unfavorable  when  there 
is  evidence  of  marked  mental  reduction ;  for  example,  in  cases 
where  the  signs  of  mental  depression  and  apprehensiveness  or 
anxiety  give  place  to  apathy  and  indifference.  As  has  already 
been  said,  the  earlier  the  systematization  of  the  insane  ideas 
the  longer  will  be  the  duration  of  the  case.  In  cases  where 
the  physical  state  becomes  rapidly  worse,  the  refusal  of  food 
marked,  and  the  changes  in  circulation  assume  an  ominous 
character,  death  may  follow  from  pure  exhaustion.  The  oc- 
currence of  various  disorders,  such  as  Bright's  disease,  an  en- 
docarditis, or  pneumonia,  increases  the  gravity  of  the  prognosis. 
The  disease  is  much  more  frequent  in  women  than  in  men,  the 
proportion  being  as  two  to  one.  It  is  much  more  common  in 
the  married  than  in  the  unmarried,  and  in  at  least  one-half  of 
the  cases  there  seems  to  be  a  predisposition  to  alienation,  shown 
either  by  the  occurrence  of  mental  disease  in  the  parents  or 
in  the  brothers  and  sisters,  or  by  the  tendency  shown  by  the 
patient  earlier  in  life  to  become  the  subject  of  "  nervous  break- 
downs," etc.  The  tendency  to  recurrence  is  marked,  being 
present  in  at  least  15  or  20  per  cent,  of  the  cases.  When  com- 
plete recovery  does  not  ensue  the  disease  either  progresses 
until  the  symptoms  of  senile  dementia  become  well  marked  or 
the  patient  recovers  sufficiently  to  be  discharged  from  the  insti- 
tution, although  a  considerable  degree  of  mental  enfeeblement 
remains. 

The  differential  diagnosis  is  often  difficult.  Cases  occur- 
ring towards  the  end  of  the  fourth  or  the  beginning  of  the 
fifth  decade  may  very  easily  be  mistaken  for  instances  of  manic- 
depressive  insanity,  in  which  the  psychomotor  retardation  is  not 
well  marked  and  the  insane  ideas  are  not  well  developed.  The 
diagnosis  can  often  be  established  after  careful  observation  of 
the  development  of  the  disease.  The  marked  emotional  indif- 
ference characteristic  of  patients  suffering  from  dementia  prse- 
cox,  as  a  rule,  serves  to  differentiate  this  disorder  from  the 
involutional  melancholias,  as  well  as  the  disturbances  in  asso- 
ciative thinking  and  the  presence  of  obsessions  and  impulsive 


SENILE    PSYCHOSES 


591 


acts.  The  depressed  form  of  general  paresis  is,  as  a  rule,  char- 
acterized by  a  considerable  defect  in  associative  memory  and 
a  marked  general  mental  impairment,  as  well  as  by  the  occur- 
rence of  physical  symptoms. 

Treatment. — When  the  disease  is  well  developed,  unques- 
tionably the  patient  is  better  off  in  bed  and  under  the  constant 
supervision  of  a  well-trained  nurse  and  not  merely  of  an  at- 
tendant. He  should  be  carefully  isolated  from  all  disturbing 
influences,  even  the  members  of  the  family  not  having  access 
to  him.  At  the  beginning  of  the  treatment  it  is  always  better 
to  restrict  the  diet  to  fluids — milk  given  regularly  at  intervals 
of  from  two  to  three  hours  or  raw  eggs  beaten  up,  either  alone 
or  in  milk;  later,  soups,  toast,  raw  or  stewed  oysters  may  be 
added.  If  there  is  any  motor  restlessness  or  any  marked  de- 
gree of  apprehensiveness  or  anxiety  present,  it  may  be  neces- 
sary to  administer  sedatives;  trional,  sulphonal,  the  bromides 
may  be  given  in  small  quantities,  but  not,  however,  until  the 
effect  of  the  bath  given  in  a  tub  at  the  bedside  or,  if  the  patient 
does  not  stand  this  well,  of  warm  packs,  has  been  tried.  As 
the  case  progresses  gentle  massage  may  be  given,  either  once 
or  twice  a  day.  The  manner  in  which  the  patient  reacts  to  this 
procedure  should  be  carefully  noted,  as  in  some  instances  it 
excites  him  so  that  sleep  is  interfered  with.  The  effect  of  the 
hydrotherapeutic  measures  is,  as  a  rule,  satisfactory.  If  the 
bathing  and  massage  are  well  borne,  the  patient  may  be  given 
cold  sprays,  but  as  this  procedure  is  apt  to  be  very  stimu- 
lating it  is  best  employed  only  in  the  morning  hours.  The 
mental  effect  of  a  good  nurse  cannot  be  overestimated,  and 
her  intelligence  should  be  of  such  a  character  as  to  be  capable 
of  arousing  and  stimulating  the  patient's  attention.  The  care- 
ful selection  and  reading  out  loud  of  good  literature  by  the 
nurse,  especially  such  as  serves  to  amuse,  is  useful  during  the 
period  of  convalescence. 

The  period  of  convalescence  is  apt  to  be  somewhat  pro- 
tracted and  the  patient  needs  to  be  carefully  guarded  against 
the  danger  of  relapse.  Not  infrequently  a  change  of  air,  a  long 
voyage,  or  a  quiet  life  in  the  country,  if  possible  under  medical 


592  PSYCHIATRY 

supervision  and  the  care  of  a  trained  nurse,  is  indicated.  No 
form  of  treatment  can  properly  be  condemned  as  severely  as 
that  frequently  advised  by  many  practitioners,  who  send  their 
patients  during  the  onset  or  height  of  the  disease  on  long  jour- 
neys or  prescribe  forced  occupation  as  the  best  means  of  in- 
suring recovery.  This  form  of  treatment,  if  it  does  not  end 
fatally,  owing  to  suicide  of  the  patient  or  some  intercurrent 
complication,  is  sure  to  add  greatly  to  the  duration  of  the 
disease,  even  although  the  proper  therapeutic  measures  may  be 
finally  instituted. 

In  addition  to  the  symptoms  of  agitated  melancholia  char- 
acterized by  motor  restlessness,  great  anxiety,  and  appre- 
hensiveness,  there  is  a  group  of  other  symptoms  deserving 
special  mention  which  occasionally  occur  in  senile  cases.  The 
majority  of  these,  however,  probably  represent  either  the  early 
stages  of  alienation  developing  on  an  arteriosclerotic  basis  or 
the  prodromal  symptoms  of  senile  dementia.  This  is  particu- 
larly true  in  regard  to  the  cases  in  which  the  hallucinations 
become  marked  and  the  mania  resembles  that  of  the  excited 
stage  of  dementia  paralytica.  There  is  the  same  expansive- 
ness,  mental  exaltation,  tendency  to  engage  in  new  occupa- 
tions, to  form  new  plans,  to  act  without  counting  the  cost. 
Wernicke  has  described  a  group  of  cases  which  he  thinks  occur 
quite  frequently  at  this  period  and  bear  a  marked  resemblance 
to  Korsakow's  symptom-complex.  This  group  of  cases  was 
described  by  the  older  writers  as  presbyophrenia  (Arndt). 
The  power  of  the  patient  to  comprehend  the  questions  ad- 
dressed to  him,  the  fact  that  it  is  possible  to  attract  the  atten- 
tion, and  the  evident  response  to  external  stimulation,  as  well 
as  the  ultimate  recovery,  are  supposed  by  some  to  differentiate 
them  from  those  terminating  in  senile  dementia.  In  general, 
these  cases  bear  a  marked  resemblance  to  those  of  mental  de- 
pression with  anxiety  and  apprehensiveness  which  have  been 
described.  There  is  marked  allopsychic  disorientation  with 
a  great  tendency  to  confabulate,  and,  as  a  rule,  the  retro- 
active amnesia  is  present.  The  emotional  changes  may  be 
characterized  as  either  an  euphoria  or  as  a  condition  in  which 


SENILE   PSYCHOSES 


593 


the  patient  is  exceedingly  irritable  and  given  to  outbursts  of 
anger.  The  disturbances  in  the  power  of  apprehension,  ac- 
cording to  Wernicke,  do  not  depend  entirely  upon  the  allo- 
psychic disorientation.  These  cases  are  apt  to  run  an  acute 
course,  lasting  from  four  to  eight  weeks,  although  in  some 
instances  they  are  more  chronic.  In  a  large  number  the 
prognosis  for  recovery  is  favorable,  but  some  end  in  senile 
dementia. 

In  addition  to  the  cases  already  mentioned,  Kraepelin  has 
described  certain  pre-senile  paranoiic  states  of  suspiciousness  in 
which  the  judgment  is  markedly  impaired  (pre-senile  Beein- 
trachtigungswahn),  the  onset  of  the  disease  being  slow  and 
insidious  and  characterized  by  the  appearance  of  hypochon- 
driacal and  persecutory  ideas.  The  latter  are  particularly 
directed  against  the  members  of  the  family  and  have  a  sex- 
ual coloring.  Associated  with  these  insane  ideas  there  are 
various  nervous  pains,  spasms,  etc.  In  a  few  instances  the 
hallucinations  play  an  important  part.  The  connected  think- 
ing, apart  from  the  appearance  of  the  insane  ideas,  is  not 
greatly  disturbed.  The  moods  are  those  of  depression  and 
apprehension,  or  sometimes  irritability  and  excitement.  The 
volitional  acts  are  at  times  replaced  by  marked  impulsivity, 
and  the  insane  ideas  generally  exert  a  dominating  force.  It 
is  not  improbable  that  some  of  these  cases  represent  examples 
of  dementia  prsecox  developing  late  in  life.  The  group  is  ill- 
defined  and  cannot  be  described  as  in  any  sense  containing  cases 
that  are  specifically  characteristic  of  this  period.  In  some  in- 
stances the  symptoms  are  characterized  by  a  slow  progression 
ending  in  the  typical  senile  dementia. 

(2)  Senile  Dementia.8 — A  sharp  line  of  distinction  be- 
tween this  and  the  preceding  group  of  cases  can  not  be  drawn. 
As  has  already  been  said,  cases  of  involutional  melancholia  may 
terminate  in  dementia  in  either  one  of  the  following  ways : 


8  Pickett,  William.  Senile  Dementia ;  a  Clinical  Study  of  Two  Hun- 
dred Cases,  with  particular  Regard  to  Types  of  the  Disease.  The  Journal 
of  Nervous  and  Mental  Disease,  No.  2,  1904. 

38 


594 


PSYCHIATRY 


In  the  first  place,  the  dementing  process  may  follow  the  attack 
of  mental  depression  without  any  break  in  the  continuity  of 
the  morbid  process;  a  condition  that  is  particularly  apt  to  be 
met  with  when  the  disease  runs  a  protracted  course  and  where 
the  systematization  of  the  insane  ideas  begins  early  and  re- 
mains more  or  less  stable.     Again,  patients  may  pass  through 


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Simple  confusional, 
143  cases. 


Excited  (maniacal), 
17  cases. 


Depressed  (melan- 
cholic), 14  cases. 


Paranoioid, 
26  cases. 


Chart  to  show  the  ages  of  patients  belonging  to  the  several  types  of  senile  dementia. 
The  figures  at  the  bottom  represent  the  ages  by  hemidecades  ;  those  at  the  side,  the  number 
of  cases  (Pickett). 


one  period  of  depression,  apparently  recover,  then  after  an 
interval  of  time  there  is  a  second  or  third  attack,  during  which 
the  mental  reduction  so  characteristic  of  the  group  under  dis- 
cussion makes  its  appearance.  Many  of  the  excited  forms 
merely  represent  the  precursory  symptoms  of  this  stage. 
Again,  dementia  may  intervene  in  a  second  type  of  cases  that 
cannot  be  distinguished  clinically  from  those  described  under 
the  arteriosclerotic  forms.  To  avoid  repetition,  the  initial 
symptoms  of  the  dementing  cases  will  not  be  referred  to  again 
in  detail,  as  they  do  not  justify  the  attempt  to  establish  more 
definite  distinctions.     The  existence  of  dementia  is  to  be  sus- 


SENILE    PSYCHOSES 


595 


pected  in  those  cases  where  the  symptoms  which  have  been 
described  persist  and  where  there  are  evidences  of  permanent 
mental  impairment,  often  distinguishable  by  the  greater  lower- 
ing of  the  faculty  of  attention  and  the  consequent  defects  in 
associative  memory.  Such  patients  are  able  to  retain  few,  if 
any,  recent  impressions,  and  at  the  end  of  even  a  few  seconds 
test  words  or  phrases  can  not  be  recalled.  As  might  be  ex- 
pected, orientation  in  time  and  place  frequently  suffers  greatly, 
and  some  patients  cannot  tell  the  hour  of  the  day  and  may 
even  be  unable  to  remember  whether  it  is  early  morning  or 
late  in  the  evening.  In  spite  of  this  marked  inability  to  recol- 
lect recent  events,  those  which  have  occurred  in  the  long  past 
are  frequently  well  remembered,  so  that  circumstances  con- 
nected with  youth  may  be  related  with  considerable  accuracy 
and  with  some  degree  of  detail. 

The  power  not  only  of  picking  up  but  also  of  elaborating 
new  impressions  becomes  less  and  less.  Hallucinations,  par- 
ticularly the  auditory  forms,  as  a  rule,  become  somewhat  more 
frequent,  and  the  patients  complain  of  hearing  strange  voices 
which  frequently  have  a  threatening  and  unpleasant  character. 
The  stability  of  the  hallucinations  is  not,  as  a  rule,  constant, 
since  they  frequently  change  with  great  rapidity. 

In  addition  to  the  auditory  and  visual  forms,  we  often 
meet  with  marked  disturbances  in  all  the  organic  sensations, 
giving  rise  to  new  or  intensifying  the  already  existing  insane 
ideas  of  suspicion  and  persecution.  The  patients  lose  faith  in 
all  those  with  whom  they  are  brought  into  contact — nurses  and 
physicians  alike  are  accused  of  attempts  to  poison  them,  of 
being  the  instruments  of  unseen  spirits,  of  the  devil,  and 
strange  and  supernatural  powers  or  influences  are  attributed 
to  them. 

The  emotional  instability  is  frequently  very  marked;  the 
patients  often  become  excessively  irritable  and  dislike  intensely 
to  be  disturbed  in  any  way.  A  simple  question  as  to  how  they 
feel  may  give  rise  to  an  extraordinary  outburst  of  temper,  when 
they  will  struggle  hard  to  get  away  from  the  examiner.  When 
left  alone  they  may  sit  still  for  hours  and  only  occasionally 


596  PSYCHIATRY 

seem  to  evince  any  interest  in  what  is  going  on  about  them. 
At  times  the  facial  expression  shows  apprehensiveness,  anxiety, 
or  even  marked  depression,  but,  as  a  rule,  in  the  terminal 
stages  is  characterized  by  a  considerable  degree  of  apathy. 
In  other  cases,  particularly  in  those  which,  clinically  as  well 
as  histologically,  bear  a  resemblance  to  dementia  paralytica, 
there  is  some  exhilaration  and  exaltation  present.  The  pa- 
tients may  converse  freely,  may  be  markedly  egocentric  and 
indulge  in  excessive  confabulation — giving  accounts  of  ex- 
traordinary journeys,  of  remarkable  deeds  they  have  per- 
formed, boasting  of  their  superhuman  powers  and  of  their 
great  mental  attainments.  In  these  cases  the  speech  compul- 
sion may  be  marked  and  the  patients  give  expression  to  their 
thoughts  in  a  way  that  may  suggest  an  inner  flight  of  ideas. 
As  a  rule,  they  are  far  less  amenable  to  external  stimuli  than 
are  individuals  suffering  from  pure  mania.  In  the  later  stages 
the  compulsion  and  flight  of  ideas  disappear  and  the  patients 
may  remain  silent  for  long  periods  of  time,  only  occasionally 
giving  expression  to  a  few  ill-defined  and  senseless  syllables. 
The  articulation,  as  a  rule,  is  much  less  impaired  than  in  cases 
of  dementia  paralytica.  In  addition  to  the  symptoms  already 
referred  to,  there  is  marked  impulsivity,  which  not  infrequently 
shows  itself  in  various  ways  which  are  of  great  forensic  impor- 
tance— theft,  arson,  attempts  at  murder,  exhibitionism,  or 
assaults  upon  children.  The  last  two,  in  nearly  all  instances, 
are  the  results  of  impulses  of  a  sexual  nature.9 

The  symptoms  already  referred  to  not  infrequently  show 
a  marked  tendency  towards  exacerbations  with  remissions  and 
occasional  transitory  delirious  states.  During  such  periods  the 
hallucinations,  insane  ideas,  as  well  as  the  motor  restlessness  and 
disturbances  of  speech,  become  much  more  marked.  As  the  dis- 
ease progresses  the  exacerbations  are  less  acute  and  the  men- 
tal reduction  becomes  more  pronounced  until  the  life  of  the 
individual  amounts  to  an  almost  purely  vegetative  existence. 


9  Hoche,    A. :     Dementia    Senilis.      Handbuch    der   gerichtlichen    Psy- 
chiatric    Hirschwald,  Berlin,  1901. 


SENILE    PSYCHOSES 


597 


No  attempt  is  made  to  eat,  and  such  patients  seldom  give  ex- 
pression to  any  feeling.  In  point  of  fact,  they  seem  to  be 
reduced  to  a  condition  in  which  there  is  a  great  deficiency  in 
the  appreciation  of  all  organic  sensations. 

The  complications  that  may  occur,  as  would  be  expected, 
are  very  varied  and  not  infrequent — attacks  of  vertigo,  stu- 
porous states,  epileptiform  attacks,  symptoms  pointing  to  focal 
lesions,  paralyses,  etc. 

Death  usually  intervenes  after  some  cerebral  complication, 
such  as  hemorrhage;  or  these  patients  are  particularly  apt  to 
develop  pneumonia,  exacerbations  of  an  existing  nephritis, 
gastro-intestinal  disturbances,  diarrhoeas,  and  not  infrequently, 
unless  the  greatest  care  is  taken,  a  general  infection,  the  result 
of  a  bed-sore. 

The  differential  diagnosis  in  the  typical  cases  is  not  diffi- 
cult. But  in  some  of  the  atypical  forms  there  may  be  inequality 
of  the  pupils,  impairment  of  the  light  reflex  with  disturbances 
of  speech,  and  euphoria,  so  that  the  clinical  differentiation  from 
cases  of  dementia  paralytica  is  exceedingly  difficult  and,  in 
fact,  frequently  impossible.  Cases  of  manic-depressive  insan- 
ity which  develop  late  in  life  may  give  rise  to  considerable 
difficulty.  Frequently  it  is  necessary  to  wait  until  the  termina- 
tion of  the  attack  before  a  positive  opinion  may  be  ventured. 
As  a  rule,  the  dementing  process  seldom  makes  its  appearance 
before  the  middle  of  the  seventh  decade.  If  the  history  of  the 
case  shows  that  the  patient  has  not  been  subject  to  any  form 
of  mental  aberration  prior  to  this  period  of  life,  the  occurrence 
of  the  symptoms  of  senile  dementia  may  be  more  easily  recog- 
nized than  in  persons  who  have  suffered  from  other  psychoses, 
particularly  when  little  or  nothing  is  known  in  regard  to  the 
factors  of  immediate  etiological  importance.  The  general  con- 
sensus of  opinion  among  clinicians  is  that  the  hereditary  factor 
is  not  one  of  great  importance.  The  baneful  influences  due 
to  the  stress  and  strain  of  social  conditions,  and  such  factors  in 
the  environment  of  the  patient  as  tend  to  prevent  the  enjoy- 
ment of  old  age  with  ease  and  dignity,  may  be  considered  as 
provocative. 


598  PSYCHIATRY 

The  pathological  changes  in  senile  dementia  vary  in  inten- 
sity and  extent  from  those  described  as  occurring  during  the 
period  of  old  age.  There  is  a  general  rarefaction  of  the  tissues 
with  marked  chronic  cell  changes  and  some  increase  in  the  glia. 
In  typical  cases  the  vascular  changes,  although  present,  are 
relatively  so  trivial  that  they  can  not  be  the  sole  cause  of  the 
other  lesions  in  the  cortex. 

It  is  not  possible  as  yet  to  refer  the  variations  in  individual 
clinical  pictures  to  fundamental  differences  in  structural  lesions. 
Meyer 10  has  described  changes  occurring  in  the  brain  in  a 
number  of  cases,  particularly  in  the  end  stages  of  depressive 
disorders,  near  or  after  the  climacteric  period.  These  lesions 
he  attributes  to  a  central  neuritis,  using  the  term  as  an  equiva- 
lent of  parenchymatous  neuritis  mainly  of  central  distribution. 
The  symptoms,  as  a  rule,  are  vague,  consisting  chiefly  in  diffi- 
culty in  locomotion  and  in  the  coordination  of  movements, 
jactitation  of  the  limbs,  febrile  disturbances,  attacks  of  diar- 
rhoea, followed  by  a  terminal  period  in  which  the  mental  state 
is  one  of  apprehensiveness,  delirium,  or  stupor. 

The  forensic  importance  of  these  cases  is  considerable, 
a  fact  that  may  be  referred  in  part  to  the  amnesias,  the  occur- 
rence of  insane  ideas,  to  the  occasional  impulsivity  of  the 
patients,  and  the  marked  emotional  anomalies. 

The  treatment  is  purely  symptomatic.  As  a  rule,  patients 
are  better  off  in  an  institution  where  they  can  have  the  benefit 
of  careful  medical  supervision,  trained  nursing,  hydrotherapy, 
massage,  etc.  Such  persons  are  particularly  prone  to  show 
great  animosity  and  to  become  much  more  intractable  when 
surrounded  by  the  members  of  their  own  family. 

10  Meyer,  Adolf  :    On  Parenchymatous  Systemic  Degenerations.    Brain, 
vol.  xxiv  (1901),  p.  47. 


INDEX 


Abulia,  123,  454;  in  hysteria,  495, 
498,    503;     in    neurasthenia,    516, 

533- 

Acarophobia,  520. 

Acathisia,  526. 

Acute  alcoholic  hallucinosis,  300; 
Pathogenesis  of,  303. 

Acute  confusional  insanity,  266. 

Acute  delirium,  261 ;  Physical 
symptoms  of,  263 ;  Termination 
of,  264;    Treatment  of,  265. 

Age  as  a  cause  of  insanity,  196. 

Agoraphobia,   526,   528. 

Akinesia  algera,  520,  526;  in  manic- 
depressive  insanity,  351 ;  in  senile 
psychoses,   579. 

Akoasmata,   59,  63,  293. 

Alcohol,    17,   62,   91,  215,   240,   542, 

557- 

Alcohol,  Abnormal  psychic  states 
due  to,  10,  13,  304;  Action  of, 
upon  psychic  activities,  287 ;  Ef- 
fect of,  upon  muscles,  286. 

Alcohol,  Intolerance  for,  287;  in 
arteriosclerosis,  288,  552;  in  epi- 
lepsy, 287 ;  in  hysteria,  287 ;  in 
neurasthenia,  287 ;  in  paresis,  287, 
427;  in  dementia  praecox,  287, 
390 ;  following  trauma,  287 ;  in 
syphilitic  psychoses,  561. 

Alcoholic  humor,  305. 

Alcoholic  intoxication,  Unusual 
forms  of,  289. 

Alcoholics,  Psychical  disturbances 
in,  62. 

Alcoholism,  37,  71,  129,  135,  186,  188, 
204,  219,  285,  334,  363,  453,  455, 
487,  488,  507,  548,  549;  Compli- 
cations during,  308;  Emotional 
anomalies  in,  290;  Etiology  of, 
309;  in  epilepsy,  486;  in  paresis, 
418,  424,  426,  444;  Pathological 
anatomy  of,  312;  Psychomotor 
excitability  in,  93 ;  Treatment  of, 
309. 

Alcoholism,  Chronic,  24,  274,  457; 
Differential  diagnosis  from  Amen- 
tia, 274;  Paranoiic  and  dement- 
ing states  developing  during, 
304- 

Algolagnia,  108. 


Amaurotic  family  idiocy,  245. 

Amentia  (Meynert),  188,  205,  209, 
216,  227,  256,  263,  266,  363,  407, 
549,  560,  565 ;  Catatonic  symp- 
toms in,  408,  409;  Course  of, 
269 ;  Differential  diagnosis  of, 
274;  Disorientation  in,  87,  268, 
407 ;  Dissociation  in,  267 ;  Eti- 
ology of,  273 ;  Fear  in,  267 ; 
Forms  of,  269;  Incidence  of,  270, 
273 ;  Pathology  of,  275 ;  Physi- 
cal symptoms  of,  269;  Prog- 
nosis in,  270 ;  Termination  of, 
270;    Treatment  of,  274. 

Amnesia,  82,  308,  485 ;  in  alcohol- 
ism, 290;  in  epilepsy,  475,  480; 
in  hysteria,  495,  497,  498,  500,  503 ; 
in  neurasthenic  states,  521 ;  in 
paresis,  420;  in  post-epileptic 
mental  disturbances,  480. 

Amyotrophic  lateral  sclerosis,  546. 

Anaemias,  130,  208,  298,  487,  488 ; 
Apathy  in,  209;  Exaltation  in, 
209;  Irritability  in,  208;  Psycho- 
motor retardation  in,  209. 

Anaesthesias,  in  alcoholic  paranoiic 
states,  305 ;  in  hysteria,  495,  496, 
503,  511;  in  Korsakow's  syn- 
drome, 278. 

Analgesias  in  paresis,  423. 

Anarchasma,  524. 

Anencephalic  monsters,  231. 

Angst,  585. 

Antikineses,  89. 

Antiklises,  89. 

Anxiety,  109,  117,  123,  138,  269; 
Blood-pressure  in  states  of,  118; 
Classification  of  states  of,  118; 
Neural  disturbances  in  states  of, 
117;  in  acute  alcoholic  halluci- 
nosis, 300,  301 ;  in  delirium  acu- 
tum,  262 ;  in  delirium  tremens, 
295 ;  in  epilepsy,  475,  476,  477,  479, 
480 ;  in  hysteria,  507,  508 ;  in 
Korsakow's  syndrome,  280;  in 
manic-depressive  insanity,  351, 
354,  355,'  in  morphinism,  317;  in 
myxedematous  alienation,  329 ; 
in  paresis,  425,  443  ;  in  senile  psy- 
choses, 369,  578,  585,  588,  590,  591, 
592,  596. 

599 


6oo 


INDEX 


Anxiety  of  cortical  origin  as  dis- 
tinguished from  praecordial  anx- 
iety, 118. 

Anxiety  psychoses,  228,  585. 

Apathy,  131,  138,  238;  associated 
with  brain  abscess,  548;  asso- 
ciated with  brain  tumors,  549; 
Disorientation  in,  87;  following 
apoplexy,  546 ;  in  anaemia,  209 ; 
in  delirious  states,  117;  in  de- 
mentia paranoides,  398;  in  de- 
mentia praecox,  378,  379,  380,  381, 
386,  387,  388,  392,  395,  406;  in 
epilepsy,  480 ;  in  Huntington's 
chorea,  223;  in  morphinism,  318; 
in  myxoedematous  alienation,  327 ; 
in  paresis,  414,  425,  445,  448,  455, 
457 ;  in  post-epileptic  mental  dis- 
turbances, 480;  in  senile  psy- 
choses, 590. 

Aphasia,  204,  308,  559;  in  arterio- 
sclerotic psychoses,  552 ;  in  pare- 
sis, 421,  449,  452,  456;  Amnesic, 
in  migraine,  221. 

Apoplexy,  129;  Mental  anomalies 
associated  with,  546. 

Apoplectiform  attacks,  264,  451, 
456;    in  syphilitic  psychoses,  561. 

Apperception  in  paranoia,  567. 

Apprehensiveness,  12,  123,  138,  216, 

266,  483,  484,  541 ;  and  praecor- 
dial  oppression,   71 ;    in   amentia, 

267,  269;  in  delirium  acutum, 
262 ;  in  delirium  tremens,  291 ;  in 
epilepsy,  456 ;  in  Graves'  dis- 
ease, 333 ;  in  Korsakow's  syn- 
drome, 280;  in  manic-depressive 
insanity,  351 ;  in  melancholia, 
523;  in  morphinism,  317;  in  neu- 
rasthenia, 516;  in  paresis,  425, 
443,  445 ;  in  psychasthenic  states, 
533,  536 ;  in  senile  psychoses,  578, 
579,  585,  586,  588,  590,  591,  592, 
593,  596. 

Aprosexia,  51,  497. 

Argyll-Robertson  pupil  in  paresis, 
250,  409,  433,  458. 

Arithmomania,  525. 

Arteriosclerosis,  23,  204,  216,  306, 
308,  547,  55p. 

Arteriosclerotic  atrophy,  24. 

Arteriosclerotic  changes  in  paresis, 
469. 

Arteriosclerotic  psychoses,  550;  Di- 
agnosis of,  553  ;  Grouping  of,  556 ; 
Incidence  of,  551 ;  Pathological 
changes  in,  555 ;  Treatment  of, 
558.. 

Association,  see  also  Memory,  Asso- 
ciative. 


Association,  Disturbances  of,  73; 
in  acute  alcoholic  hallucinosis, 
304;  in  dementia  praecox,  381, 
388;  in  hysteria,  504;  in  manic- 
depressive  insanity,  342,  343,  351, 
354,  355 ;  in  myxoedematous 
alienation,  328 ;  in  paresis,  420, 
422. 

Associationism,  Doctrine  of,  73. 

Associative  activities  of  the  brain 
and  reflex  and  volitional  acts,  52. 

Associative  thinking,   102,   103,   105. 

Astasia  abasia,  498. 

Asymbolism  in  epilepsy,  479. 

Ataxia  in  bromism,  323 ;  in  paresis, 
440. 

Atrophy,  Cortical,  in  senescence, 
577- 

Attention,  7,  30,  48,  53,  57,  67,  76, 
77,  115,  294,  561;  Disorders  of, 
48;  in  alcoholism,  51,  286;  in 
amentia,  267 ;  in  chorea,  222 ;  in 
cretinism,  331 ;  in  delirium  tre- 
mens, 294;  in  fatigue,  199;  in 
flight  of  ideas,  76;  in  Graves' 
disease,  333 ;  in  hepatic  disease, 
217;  in  hypomania,  357;  in  hys- 
teria, 495,  496,  497,  500,  503;  in 
idiocy,  232,  234,  239;  in  manic- 
depressive  insanity,  342,  343 ;  in 
myxoedematous  alienation,  2>27  > 
in  neurasthenic  states,  519,  521; 
in  paranoia,  568 ;  in  paresis,  420, 
443,  448,  454;  in  pseudo-paresis, 
214;  in  senile  psychoses,  585, 
588,  595 ;  in  syphilitic  psychoses, 
561;  in  volitional  acts,  50;  Te- 
nacity of,  50 ;  Tetanization  of, 
30,  102,  116,  343;    Virgility  of,  50. 

Audible  thinking,  60,  61,  584. 

Auditory  hallucinations,  57,  60,  62, 
64,  65,  66;  in  acute  alcoholic 
hallucinosis,  300,  303,  304;  in 
acute  delirium,  263 ;  in  cocain- 
ism,  322,  323 ;  in  delirium  tre- 
mens, 292,  293 ;  in  dementia  prae- 
cox, 397 ;  in  epilepsy,  476,  478 ; 
in  fever  deliria,  258;  in  Graves' 
disease,  334;  in  hepatic  disease, 
217;  in  hysteria,  496,  507;  in 
Korsakow's  syndrome,  279 ;  in 
meningitis,  547;  in  morphinism, 
318,  320;  in  paraldehyde  intoxi- 
cation, 316;  in  paranoia,  571;  in 
paresis,  439,  443,  447,  452 ;  in  psy- 
chasthenic states,  531;  in  senile 
psychoses,  584,  595. 

Aufmerksamkeit,  102. 
Aurae,    in    epilepsy,    475,    476,    480; 
Visual,  in  epileptic  migraine,  221. 


INDEX 


60 1 


Autointoxication,  23,  no,  212,  215, 
220,  227,  254,  260,  276,  315,  411, 

537,  545- 
Automatism,  70,  90,  96,  139;  in  .de- 
mentia prsecox,  368,  389,  396,  397, 
401 ;     in   epilepsy,  475,   480,  482 ; 
in  hysteria,   499. 

Baillarger's  division  of  hallucina- 
tions, 59. 

Basedow's  disease,  Mental  disor- 
ders associated  with,  ^33- 

Bekanntheitsgefiihl,  83. 

Bell's  disease,  261. 

Bile-ducts,  Mental  disturbances 
after  operations  upon  the,  218. 

Blood  and  lymph  channels  of  the 
central  nervous  system,  21. 

Blood,  in  delirium  tremens,  296,  299  ; 
in  manic-depressive  insanity,  346. 

Blood-pressure,  in  anxiety,  118;  in 
delirium  tremens,  296;  in  de- 
mentia prsecox,  402 ;  in  depres- 
sion, 116;  in  emotional  storms, 
118;  in  manic-depressive  insan- 
ity, 345,  351.  37i ,"  in  senile  psy- 
choses, 588;  Intraocular,  condi- 
tioning visual  hallucinations,  64 ; 
Relation  of,  to  mental  states,  216. 

Brain  abscess,  Psychoses  associated 
with,  548. 

Brain  tumors,  Psychoses  associated 
with,   548. 

Bridgman,  Laura,  Case  of,  28. 

Bromism,  323. 

Bulimia  in  manic-depressive  insan- 
ity, 349- 

Caffein,  Abnormal  psychic  states 
due  to,  10. 

Cardiac  and  vascular  disease  as 
causes  of  insanity,  215. 

Cardiac  and  vascular  disturbances 
in  non-myxoedematous  infantil- 
ism, 243. 

Catalepsy,  411. 

Cataleptic  phenomena  in  post-epi- 
leptic mental   disturbances,   480. 

Cataleptic  state,  99,  385,  401. 

Catatonia,  204,  373,  401,  404,  411, 
453  ,'    Orientation  in,  87. 

Catatonic,  excitement,  250,  394,  485 ; 
form  of  dementia  precox,  391 ; 
rigidity  in  paresis,  409,  430 ; 
states,  24,  98 ;  stupor,  392 ;  symp- 
tom-complex, 13,  87;  symptoms 
in  psychoses  other  than  dementia 
prsecox,  409. 

Cerea  flexibilitas  in  catatonic  form 
of  dementia  prsecox,  392,  393,  408. 


Cerebrasthenia,  518. 

Cerebropathia  psychica  toxsemica, 
277. 

Cerebrospinal  fluid,  Examination 
of,  143. 

Chloroform,  Psychoses  following 
the  administration  of,  315. 

Chondrodystrophia   fcetalis,  244. 

Chorea,  269,  509 ;  and  epilepsy,  223 ; 
gravidarum,  223 ;  Huntington's, 
95,  223,  224;    insaniens,  222,  223. 

Christian   Science,  30,  398. 

Circular  Insanity,  336,  353,  360. 

Circumstantiality,  140. 

Clairvoyance,  398. 

Claustrophobia,  528. 

Cocainism,  322. 

Ccensesthesia,  71,  106. 

Ccenaesthetic  euphoria  in  paresis, 
423- 

Collapse  delirium,  261. 

Collectionism  in  arteriosclerotic 
psychoses,  554. 

Coma,  204,  439 ;  hepaticum,  218 ;  in 
lead-poisoning,  325  ;  in  morphin- 
ism, 320;  in  myxoedematous 
alienation,  329;    vigil,  259. 

Combined  psychoses,  228. 

Composite  psychoses,  229. 

Conduct,  Anomalies  of,   119,  196. 

Confabulation,  137,  141,  277,  278, 
294,  302,  596. 

Confusion,  24,  105,  271,  2>72^  536, 
560;  after  operations  on  the  bile- 
ducts,  218 ;  in  bromism,  323 ;  in 
chorea,  222  ;  in  dementia  prsecox, 
391 ;  in  Korsakow's  syndrome, 
277,  279,  282;  in  manic-depres- 
sive insanity,  351. 

Confusional  insanity,  266. 

Confusional  states,  23,  209,  210,  227, 
260,  266,  273,  407. 

Consciousness,  12,  30,  31,  53,  55,  56, 
57,  67,  76,  78,  99,  100,  101,  104, 
no,  113,  115,  135,  142,  266,  522; 
Allopsychic,  69,  70,  142;  Auto- 
psychic,  69,  70,  142,  426;  in 
alcoholism,  289,  292,  295,  300; 
in  amentia,  267,  268 ;  in  de- 
lirium acutum,  263 ;  in  dementia 
prsecox,  382 ;  in  epilepsy,  476,  477, 
478,  479,  480,  485,  512;  in  fever 
deliria,  258,  259;  in  hysteria,  503, 
504,  506,  511;  in  hysterical  de- 
lirious states,  508 ;  in  Korsakow's 
syndrome,  280,  282 ;  in  manic- 
depressive  insanity,  343  ;  in  men- 
ingitis, 547;  in  paranoia,  566, 
567;  in  paresis,  451,  452,  456;  in 
psychasthenic      states,      532;       in 


602 


INDEX 


senile  psychoses,  585,  588;  So- 
matopyschic,  69,  70,  94,  142, 
351 ;     Transitory  disturbances  of, 

485- 

Convulsions,  129;  in  morphinism, 
320;  in  myxoedematous  aliena- 
tion, 329. 

Coprolalia,  96. 

Craniostenosis,  244. 

Cretinism,  329;  Differential  diag- 
nosis of,  333;  Grouping  of,  332; 
Mental  symptoms  of,  331 ;  Path- 
ology of,  332;  Physical  symp- 
toms of,  330;    Treatment  of,  333. 

Crises  angoissantes,  104. 

"  Critical  age,"  61. 

Cyclothemia,  369. 

Cytodiagnosis  in  paresis,  455. 

Daily  life  and  paresis,  419. 

Defect  psychoses,  see  also  Idiocy 
and  Imbecility. 

Defect  psychoses,  185,  227,  229; 
Diagnosis  in  the  acquired,  250; 
Pathology  of,  244;  Treatment 
of,  251. 

Defence  movements,  97. 

Degeneracy,  Signs  of,  185 ;  Stig- 
mata of,  in  paresis,  416. 

Degenerates,  107,  125,  416;  Ferri's 
grouping  of,  124. 

Degenerative  psychoses,  517. 

Delire,  ecmnesique,  503,  507 ;  du 
contact,  527;  du  doute,  531;  du 
scruple,  536;    onirique,   105. 

Delira,  Diagnosis  in,  259;  Fever, 
23,  210,  216,  227,  254;  Grouping 
of,  255,  258;  in  meningitis,  547; 
Prognosis  in,  259;  Systematized, 
105  ;   Treatment  of,  259. 

Delirious  mania,  266. 

Delirious  states,  196,  206,  209,  227, 
254,  280,  290,  407,  449,  559,  596; 
in  arteriosclerotic  psychoses,  554; 
in  chorea,  222 ;  in  chloroform 
psychoses,  315 ;  in  cocainism, 
322;  in  heart  disease,  215;  in 
hysteria,  507 ;  in  morphinism, 
320;  in  tobacco  intoxication,  324; 
Apathy  in,  117;  disorientation 
in,  87. 

Delirium,  67,  84,  205,  213,  427,  428, 
438,  439,  440. 

Delirium  acutum,  24,  216,  261,  266, 
267,  268,  269,  457,  483 ;  Physical 
symptoms  of,  263 ;  Termination 
of,  264;  Treatment  of,  265. 

Delirium,  Collapse,  209,  227,  256, 
261 ;  grave,  261 ;  in  cases  of 
brain    tumor,    549;     in    lead-poi- 


soning, 325;  in  neurasthenia,  516; 
Initial,  255 ;    of  negation,  36. 

Delirium,  Subacute  states  of,  and 
mental  confusion,  266. 

Delirium  tremens,  24,  58,  265,  282, 
291,  565 ;  Abortive  form  of, 
297;  Adynamic  form  of,  297; 
Course  of,  296 ;  Disorientation  in, 
87;  Hallucinations  in,  292 ;  Inci- 
dence of,  299;  Pathogenesis  of, 
298;  Physical  symptoms  of,  296; 
Speech  disturbances  in,  294; 
Tremor  in,  295,  297. 

Delirium,  Ursemic,  220. 

Delusions,  12,  61,  95,  100,  no,  118, 
119,  132,  138,  258,  264,  266;  after 
operation  on  the  bile-ductsr  218; 
in  acute  alcoholic  hallucinosis, 
301,  304;  in  alcoholic  paranoiic 
states,  304,  305 ;  in  delirium  tre- 
mens, 297 ;  in  dementia  para- 
noides, 397;    in  dementia  prsecox, 

377,  388,  392,  394 ;  in  epilepsy,  475, 
476,  479;  in  Korsakow's  syn- 
drome, 278,  279;  in  morphinism, 
318;  in  paranoia,  570;  in  paresis, 
414,  446,  447 ;  in  senile  psychoses, 
580 ;  systematized,  in  involutional 
melancholia,  369. 

Demence  Precoce  des  jeunes  gens, 

372. 
Dementia,    55,    57,   84,   92,   93,    116, 

228,  372,  373,  449,  559,  562 ;  after 
apoplexy,  546,  547,  554 ;  Epileptic, 
474,  482,  492 ;  in  multiple  sclero- 
sis, 545  ;  in  myxoedematous  alien- 
ation, 328;  in  paresis,  438,  443, 
444,  446,  449;    Luetic,  561. 

Dementia  paralytica,  see  also  Pare- 
sis. 

Dementia  paralytica,  17,  18,  20,  22, 
24,  32,  85,  196,  202,  204,  216,  226, 

229,  250,  266,  274,  282,  306,  374, 

378,  413,  483,  509,  518,  539,  541, 
545,  548,  562,  576,  578,  592,  596, 
597;  group,  13. 

Dementia  paranoides,  397;  Apathy 
in,  398;  Delusions  in,  397;  De- 
pression in,  398;  Dissociation  in, 
398 ;  Disturbances  of  volition  in, 
398 ;  Hallucinations  in,  397 ; 
Ideas  of  persecution  in,  397 ;  Im- 
pulsivity  in,  399;  Insane  ideas  in, 
397,  398;  Megalomania  in,  397, 
398;    Stereotypies  in,  399. 

Dementia,  Post-traumatic,  201. 

Dementia  prsecox,  14,  32,  75,  121, 
135,  137,  T87,  193,  206,  216,  221, 
227,  229,  250,  256,  260,  266,  271, 
274,  328,  334,  337,  338,  357,   360, 


INDEX 


603 


368,  369,  468,  478,  480,  485,  509, 
Sio,  518,  539,  549,  565,  500,  593; 
Apathy  in,  378,  379,  380,  381,  386, 
387,  406;  Association  in,  381; 
Automatism  in,  368,  389,  396,  397, 
400 ;  Blood-pressure  in,  402 ;  Com- 
plexion in,  401 ;  Consciousness 
in,  382 ;  Cyanosis  in,  216,  402 ; 
Delusions  in,  377 ;  Depression  in, 
379,  396,  402,  406;  Differential 
diagnosis  of,  405 ;  Dissociation 
in,  380,  385,  392,  406;  Emotional 
anomalies  in,  376,  378,  379,  387, 
400;  Emotional  storms  in,  377, 
379)  388,  393 ;  Environment  in, 
404;  Etiology  of,  404;  Gait  in, 
383 ;  Grouping  of,  374 ;  Halluci- 
nations in,  377,  381 ;  Heredity  in, 
404 ;  Hypochondriasis  in,  378 ; 
Ideas  of  persecution  in,  397;  Il- 
lusions in,  381 ;  Imperative  con- 
ceptions in,  379;  Impulsivity  in, 
369,  377,  392,  395,  397,  400,  406, 
408 ;  Incidence  of,  375 ;  Inhibi- 
tion in,  386,  400;  Insane  ideas  in, 
378,  381 ;  Intellectual  anomalies 
in,  376,  380;  Intrapsychic  inco- 
ordination in,  114;  Irrelevancy 
in,  368,  383,  510;  Lucid  intervals 
in,  400;  Mannerisms  in,  369,  386, 
396,  397,.  400,  404,  405,  sio;  Me- 
galomania in,  378;  Memory  in, 
378 ;  Mirror  writing  in,  383 ; 
Motor  anomalies  in,  369,  386; 
Muscular  irritability  in,  402,  411; 
Negativism  in,  381,  386,  389,  396, 
400,  405,  407 ;  Obsessions  in,  377 ; 
Orientation  in,  381 ;  Parsesthesias 
in,  377,  382 ;  Pathology  of,  409 ; 
Physical  symptoms  of,  401 ;  Pro- 
dromal symptoms  of,  376 ; 
Pseudo-hallucinations  in,  378 ; 
Psychic  hallucinations  in,  378 ; 
Psychical  reaction  in,  380 ;  Psy- 
cho-ansesthesias  in,  377  ;  Pulse  in, 
402 ;  Pupils  in,  402 ;  Reflexes  in, 
402 ;  Reticence  in,  381 ;  Saliva- 
tion in,  402;  Sensations  in,  377, 
378,  381 ;  Sense  of  deficiency  in, 
381 ;  Speech  in,  383,  385  ;  Stereo- 
typies in,  382,  385,  386,  389,  392, 
395,  396,  400,  404,  405,  407 1  Stupor 
in,  386,  396,  401  ;  Suspiciousness 
in,  379,  381  ;  Sweating  in,  402 ; 
Temperature  in,  402 ;  Terminal 
stage  of,  400 ;  Tics  in,  95 ;  Train 
of  thought  in,  381 ;  Treatment  of, 
412 ;  Tremor  in,  402 ;  Tubercu- 
losis in,  210;  Vasomotor  dis- 
turbances in,  216,  402 ;  Verbigera- 


tion in,  369,  385,  396,  397,  405; 
Weight  in,  404;  Writing  in,  383. 
Dementia  prsecox,  Catatonic  form 
of,  391;  Apathy  in,  392,  395; 
Cerea  flexibilitas  in,  392,  393,  408 ; 
Confusion  in,  391 ;  Course  of, 
396;  Delusions  in,  392,  394;  De- 
pression in,  391,  392,  394,  395, 
510;  Dissociation  in,  392;  Ex- 
citement in,  391,  394,  510;  Facial 
expression  in,  393;  Hallucina- 
tions in,  394;  Hypochondriasis 
in,  392 ;  Impulsivity  in,  392,  395  ; 
Inhibition  in,  394;  Memory  in, 
394 ;  Motor  disturbances  in,  391 ; 
Muscular  rigidity  in,  393 ;  Mutism 
in,  391;  Negativism  in,  391,  510; 
Respiration  in,  394;  Sensory  dis- 
turbances in,  395 ;  Speech  in, 
395 ;    Stupor  in,  391,  392,  394,  395. 

Dementia  prsecox,  Hebephrenic 
form  of,  386;  Apathy  in,  388; 
Association  in,  388;  Delusions 
in,  388;  Depression  in,  386,  388; 
Emotional  storms  in,  388;  Ethi- 
cal defects  in,  390;  Facial  ex- 
pression in,  388;  Hallucinations 
in,  386,  388 ;  Illusions  in,  386 ;  In- 
somnia in,  388;  Irrelevancy  in, 
389,  390;  Irritability  in,  387; 
Memory  in,  388,  389;  Onset  of, 
387 ;  Orientation  in,  389,  390 ; 
Paresthesias  in,  388;  Sensations 
in,  388 ;  Speech  compulsion  in, 
388 ;  Suspiciousness  in,  388 ; 
Volitional  disturbances  in,  388. 

Dementia  prsecox,  Paranoiic  form 
of,  396;  Hallucinations  in,  396: 
Hypochondriasis  in.  397 ;  Im- 
pulsivity in.  397 :  Insane  ideas  in, 
396,  397;    Speech  in,  397. 

Dementia  prsecox,  Simple  dement- 
ing form  of,  390. 

Dementia  prsecox  complicated  by 
syphilitic  infection,  229. 

Dementia  prsecox  group,  372. 

Dementia,  Senile,  457,  518,  556,  578, 
592,  593  ;  Differential  diagnosis  in, 
597 ;  Forensic  importance  of, 
598;  Pathological  changes  in, 
598;    Treatment  of,  598. 

Dementia  simplex,  372,  374,  386. 

Dementing  and  paranoiic  states  due 
to  alcohol,  304. 

Dementing  processes,   353. 

Demensa  primitiva,  372,  374. 

Demoniac  possession,  30. 

Depression,  44,  55,  72,  76,  98,  109, 
112,  116,  119,  123,  130,  132,  138, 
140.   141,   193,   19s,  205,  210,  213, 


604 


INDEX 


215,  216,  22i,  228,  308,  323,  353, 
359,  363,  364,  365,  369,  379,  402, 
455 ;  after  operation  on  the  bile- 
ducts,  218;  associated  with  brain 
abscess,  548 ;  associated  with 
gout,  212;  in  alcoholic  paranoiic 
states,  306;  in  arteriosclerotic 
psychoses,  553 ;  in  chorea,  222 ;  in 
delirium  tremens,  291 ;  in  demen- 
tia paranoides,  398;  in  dementia 
praecox,  379,  386,  388,  391,  392, 
394,  395,  396,  402,  406,  510;  in 
epilepsy,  474,  475,  477,  489;  in 
Graves'  disease,  333,  334,  335  5 
in  Huntington's  chorea,  223; 
in  hysteria,  507,  508,  514;  in 
manic-depressive  insanity,  350, 
351,  354,  368,  511;  in  multiple 
sclerosis,  545 ;  in  myxcedematous 
alienation,  328,  329;  in  neuras- 
thenia, 516,  522,  523 ;  in  paranoia, 
568;  in  paresis,  414,  425,  427, 
431,  436,  439,  440,  444,  446;  m 
psychasthenic  states,  530 ;  in  senile 
psychoses,  578,  579,  585,  590,  593, 
594,  596;  in  syphilitic  psychoses, 
559,  560,  561 ;  in  tobacco  intoxi- 
cation, 324. 

Depression,  Disorientation  in,  87; 
Isolation  in  treatment  of,  157; 
Psychomotor  retardation  in,  93. 

Depressive  phase  of  manic-depres- 
sive insanity,  349. 

Dermatographia  in  neurasthenic 
states,  537 ;  in  senile  psychoses, 
589.   . 

Desequilibres,  518. 

Diabetes  and  glycosuria,  212,  487, 
488,  552. 

Diet,  158;  in  alcoholism,  310;  in 
arteriosclerotic  psychoses,  557, 
558;    in  senile  psychoses,  591. 

Dipsomania,  530. 

Dipsomaniacal  impulses  in  epilepsy, 

474- 

Disorientation,  see  also  Orientation. 

Disorientation,  86,  295,  297 ;  in 
acute  delirium,  262,  263 ;  in 
amentia,  87,  268,  407;  in  brom- 
ism,  323 ;  in  cerebral  syphilis, 
458;  in  chloroform  psychoses, 
315;  in  epilepsy,  290,  407,  479; 
in  fever  deliria,  258,  250 ;  in 
initial  delirium,  257;  in  Korsa- 
kow's  syndrome,  282 ;  in  manic 
stupor,  87;  in  unproductive 
mania,  355. 

Dissociation,  no,  411;  in  amentia, 
267 ;  in  dementia  paranoides,  398 ; 
in  dementia  praecox,  380,  385,  392 ; 


in  epilepsy,  478;  in  hysteria,  499, 
500;  in  manic-depressive  insan- 
ity, 75,  352,  355,  357;  in  paresis, 
423,  427. 

Distractibility,  141 ;  associated  with 
brain  tumors,  549;  in  amentia, 
267;  in  hepatic  disease,  217;  in 
hysteria,  497 ;  in  neurasthenia, 
521 ;  in  paresis,  420,  422,  440,  444, 
448. 

Dreams  in  senile  psychoses,  588. 

Dream  states,  36,  132,  135;  epilep- 
tic, 479,  488;    hysterical,  503. 

Dromomania,  70,   196. 

Drugs,  Abnormal  psychic  states 
due  to,  10,  285. 

Dysarthria,  430. 

Dyslalia,  430. 

Dyslogia,  430. 

Dysphasia,  430. 

Echolalia,  98,  102,  385,  484. 

Echopraxia,  98,  385. 

Education  and  insanity,  197. 

Egotism,  in  manic-depressive  in- 
sanity, 365,  368;  in  mental  de- 
bility, 238. 

Electrotherapy,  160. 

Embolophrasia,  96. 

Emotion,  12,  27,  30,  53,  57,  69,  108, 
i32,_  258,  273. 

Emotional  anomalies,  101,  195,  311; 
in  alcoholism,  290 ;  in  arterio- 
sclerotic psychoses,  553 ;  in  co- 
cainism,  322 ;  in  delirium  tremens, 
295 ;     in    dementia    praecox,    376, 

378,  379,  387,  400;  in  epilepsy, 
115,  475,  477;  in  Huntington's 
chorea,  223 ;  in  hypomania,  356, 
357 ;  in  imbecility,  236 ;  in  Kor- 
sakow's  syndrome,  279 ;  in  manic- 
depressive  insanity,  344,  350,  351, 
354;  in  neurasthenia,  114,  115, 
521,  523 ;  in  non-myxcedema- 
tous  infantilism,  243 ;  in  para- 
noia, 568,  571 ;  in  paresis,  425, 
427,  439,  455;  in  post-epileptic 
mental  disturbances,  480 ;  in  psy- 
chasthenic states,  526,  529,  540; 
in  senile  psychoses,  579,  595. 

Emotional  reactions,  94;  Disturb- 
ances in  the,  108,  125 ;  Objective 
evidence  of  neural  disturbance  in 
the,  116. 

Emotional  storms,  Blood-pressure 
in,  118;    in  dementia  praecox,  377, 

379,  388,  395;  in  epilepsy,  477, 
478 ;  in  manic-depressive  insan- 
ity, 355- 

Encephalitis,  Cortical,  24,  241,  368. 


INDEX 


6o  = 


Endarteritis,  Heubner's,  467. 

Environment  as  a  cause  of  insanity, 
186,  310. 

Epilepsia  larvata,  471. 

Epilepsy,  62,  63,  70,  84,  107,  121, 
131.  *35,  142,  181,  188,  204,  221, 
228,  241,  308,  363,  394,  473,  512, 
517;  Amnesia  in,  475,  480;  Anx- 
iety in,  475,  476,  477,  479,  480; 
Apathy  in,  480;  Apprehensiveness 
in,  456;  Aurae  in,  475,  476,  480; 
Automatism  in,  475,  480,  482 ;  Con- 
sciousness in,  476,  477,  478,  479, 
480,  485,  512;  Delusions  in,  475, 
476,  479;  Dementia  in,  482,  492; 
Depression  in,  474,  475,  477,  489; 
Dietetic  treatment  of,  490;  Dif- 
ferential diagnosis  of,  482;  Dis- 
orientation in,  290,  407,  479 ;  Dis- 
sociation in,  478 ;  Dream  states 
in,  479,  488 ;  Emotional  anom- 
alies in,  115,  475,  477;  Emotional 
storms  in,  477,  478;  Euphoria  in, 
475,  479 ;  Excitement  in,  474,  478, 
489;  Flight  of  ideas  in,  478;  Gait 
in,   484;     Hallucinations    in,   456, 

475,  476,  477,  478,  479,  480;  He- 
redity in,  486;  Ideas  of  persecu- 
tion in,  483 ;    Imperative  ideas  in, 

476,  480 ;    Impulsivity  in,  407,  474, 

477,  478,  480,  481 ;  Inhibition  in, 
475 ;  Insane  ideas  in,  477 ;  In- 
sight in,  477 ;  Intellectual  dis- 
turbances in,  475  ;  Irritability  in, 
475,  477  5  Latent,  477;  Memory 
in,  475,  479,  482 ;  Mental  disturb- 
ances resulting  from,  480;  Mental 
symptoms  in,  474,  476,  477; 
Motor  restlessness  in,  477,  478 ; 
Mutism  in,  478,  480;  Obsessions 
in,  476,  477,  478,  480 ;  Orientation 
in,  478 ;  Paranoiic  states  in,  482  ; 
Pathogenesis  of,  486;  Pathology 
of,  491 ;  Phobias  in,  475 ;  Psychic, 
196,  473,  477 ;  Psychomotor  re- 
tardation in,  480 ;  Senile,  557 ; 
Speech  in,  482,  484 ;  Speech 
compulsion  in,  478;  Stupor  in, 
290,  480 ;  Treatment  of,  489J ; 
Tremor  in,  484;  Verbigeration 
in,  478,  484. 

Epilepsy  and  chorea,  223,  484. 

Epileptic  attacks,  Grouping  of,  485. 

Epileptic,  mania,  407,  440,  478 ;  mi- 
graine, 221. 

Epileptiform  attacks,  264,  290,  308, 
369,  468 ;  in  bromism,  323 ;  in 
paresis,  451,  452,  456;  in  senile 
psychoses,  597 ;  in  syphilitic  psy- 
choses,   561,    562. 


Ergotism    as    a   cause    of    insanity, 

324. 

Erythrophobia,  529. 

Esquirol,  58,  119. 

Etat  crible,  577. 

Ether  intoxication,  314. 

Euphoria,  in  epilepsy,  475,  479;  in 
Huntington's  chorea,  223 ;  in 
multiple  sclerosis,  545 ;  in  paresis, 
368,  388,  423,  427,  430 ;  in  pseudo- 
paresis  of  syphilitic  origin,  561 ; 
in  senile  dementia,  597 ;  in  tuber- 
culosis, 210. 

Eurotophobia,  529. 

Evil  eye,  30. 

Exaltation,  116,  138,  210,  216,  289, 
353,  362,  364,  368,  596 ;  in  anaemia, 
209 ;  in  hysterical  delirious  states, 
508;  in  manic-depressive  insan- 
ity, 355  ;  in  myxedematous  alien- 
ation, 328,  329 ;  in  paranoia,  568 ; 
in  paresis,  425,  439. 

Examination,  of  patients,  127;  of 
the  cerebrospinal  fluid,  143. 

Exanthemata,  256,  258,  262,  274. 

Excitement,  57,  72,  76,  78,  no,  195, 
228,  323,  364,  368,  369,  385,  386, 
396,  402 ;  after  apoplexy,  546 ;  in 
acute  delirium,  263 ;  in  alcohol- 
ism, 290;  in  arteriosclerotic  psy- 
choses, 557;  in  chorea  gravi- 
darum, 223 ;  in  catatonic  demen- 
tia praecox,  391,  394,  510;  in  epi- 
lepsy, 474,  478,  489;  in  Graves' 
disease,  333,  334,  335;  in  hepatic 
disease,  217;  in  hysterical  para- 
noioid  states,  508 ;  in  meningitis, 
547;  in  myxedematous  aliena- 
tion, 329;  in  paresis,  414,  436, 
439,  444,  446 ;  in  senile  psychoses, 
578,  593 ;  in  syphilitic  psychoses, 
559,  56o. 

Exhaustion,  Chronic  nervous,  228, 
517,  522,  535- 

Exhaustion  in  chorea  gravidarum, 
223. 

Exhibitionism,  427,  475 ;  in  senile 
dementia,  108,  596. 

Exhilaration,  138,  195,  213,  216,  353, 
445,  511,  596;  associated  with 
brain  abscess,  548;  in  paranoia, 
568. 

Exophthalmic  goitre,  Mental  dis- 
orders associated  with,  2>2>3- 

Facial  expression,  in  arteriosclerotic 
psychoses,  553 ;  in  dementia  prae- 
cox, 388,  393;  in  depression,  116; 
in  exaltation,  116;  in  manic-de- 
pressive insanity,  341 ;    in  senes- 


6o6 


INDEX 


cence,  576;  in  senile  psychoses, 
585,  596;  indicating  emotion, 
109,  141 

Fanatics,  116. 

Fatigue,  7,  60,  100,  no,  132,  199; 
Associative  memory  in,  199;  At- 
tention in,  199;  in  arteriosclerotic 
psychoses,  552;  in  cases  of  brain 
tumor,  549;  in  hysterical  de- 
lirious states,  508;  in  multiple 
sclerosis,  544;  in  neurasthenia, 
516,  518,  519,  538;  in  paresis,  418, 
424,  446,  458;  Sensibility  in,  199; 
Toxic  products  the  result  of,  200. 

Fatigue,  Absence  of,  358 ;  in  cocain- 
ism,  323  ;  in  maniacal  states,  344 ; 
in  paresis,  446. 

Fatigue,  Effect  of,  on  ganglion 
cells,  200. 

Fear,  57,  109,  118,  228,  526;  in 
amentia,  266,  267;  of  impend- 
ing death  in  manic-depressive 
insanity,  351 ;  Pulse  in,  109  ; 
Tremor  in,  109. 

Feeding,  Forced,  159;  in  amentia, 
274;  in  catatonic  dementia  prse- 
cox,  392 ;  in  Korsakow's  syn- 
drome, 283 ;  in  morphinism,  321 ; 
in  senile  psychoses,  588. 

Feelings,  53,  55. 

Fever-change  in  nerve-cells,  260. 

Fevers  and  infectious  processes  as 
causes  of  insanity,  210. 

Flechsig,  Anatomical  studies  of,  19; 
on  treatment  of  epilepsy,  490. 

Flight  of  ideas,  76,  78,  117.  137,259, 
274,  484,  596 ;  in  amentia,  268 ; 
in  epilepsy,  478;  in  hypomania, 
357;  in  manic-depressive  insanity, 
340,  355,  368,  406,  511 ;  in  morphin- 
ism, 318;  in  paresis,  440;  Ficti- 
tious, in  epileptic  mania,  478 ; 
Sensory,  in  delirium  tremens, 
294. 

Folie,  a  deux,  191 ;  circulaire,  13, 
336;  de  la  puberte,  372;  du  pour- 
quoi,  524;  neurasthenique,  516; 
raisonnante,  357. 

Forensic  importance,  of  arterio- 
sclerotic psychoses,  554 ;  of  cloud- 
ing of  consciousness,  70;  of  dis- 
turbance in  the  volitional  pro- 
cesses, 92 ;  of  impulsive  acts  in 
epilepsy,  481 ;  of  intolerance  for 
alcohol,  288,  289;  of  senile  psy- 
choses, 596,  598 ;  of  the  simple 
dementing  form  of  dementia  prse- 
cox,  390. 

Formication  in  delirium  tremens, 
293- 


Foyers  lacunaires  de  disintegra- 
tion, 577. 

Gait,  in  dementia  prsecox,  383 ;  in 
epilepsy,  484;  in  morphinism, 
319;     in    paresis,    429. 

Ganglion-cell  hypothesis,  21. 

Gastro-intestinal  disturbances,  as 
causes  of  insanity,  130,  220,  273; 
in  acute  delirium,  264;  in  brom- 
ism,  323 ;  in  manic-depressive  in- 
sanity, 349,  354,  540;  in  morphin- 
ism, 319,  320;  in  neurasthenic 
states,  537;  in  paresis,  419,  436, 
437,  454  5  in  senile  psychoses,  588, 
597;    in  tobacco  intoxication,  324. 

Gedankenlautwerden,  60. 

Glia  changes,  24,  261 ;  in  alcohol- 
ism, 314;  in  defect  psychoses, 
246 ;  in  dementia  prsecox,  410 ; 
in  epilepsy,  493 ;  in  paresis,  465  ; 
in  senescence,  577. 

Gliarasen,  563. 

Gout,  309,  483 ;  as  a  cause  of  in- 
sanity, 211,  487,  488. 

Grand  Mai  Intellectuel,  477. 

Graves'  disease,  Mental  disorders 
associated  with,  333. 

Gray  substance,  Importance  of,  20. 

Gymnastic  exercises,  153. 

Haematoma   auris,   435. 

Hallucinations,  see  also  Auditory, 
Haptic,  Tactile,  and  Visual  hal- 
lucinations, respectively. 

Hallucinations,  12,  45,  51,  57,  67, 
92,  95,  no,  118,  119,  132,  137,  138, 
140,  142,  143,  210,  216,  258,  266, 
271,  359,  449,  483;  after  opera- 
tions on  the  bile-ducts,  218;  in 
acute  alcoholic  hallucinosis,  300, 
301,  302,  303,  304;  in  alcoholic 
paranoiic  states,  305 ;  in  amentia, 
268,  269,  407 ;  in  arteriosclerotic 
psychoses,  553 ;  in  cocainism, 
322 ;  in  delirium  acutum,  262 ; 
in  delirium  tremens,  292,  297 ;  in 
dementia  paranoides,  397;  in  de- 
mentia preecox,  377,  381,  386,  388, 
394,  396;  in  epilepsy,  456,  475, 
476,  477,  478,  479,  480;  in  fever 
delirium,  257 ;  in  Graves'  dis- 
ease, 334 ;  in  hysteria,  496 ;  in 
hysterical  delirious  states,  508 ; 
in  initial  delirium,  257;  in  Kor- 
sakow's syndrome,  278,  279,  280, 
282 ;  in  lead-poisoning,  325 ;  in 
manic-depressive  insanity,  342, 
352  ;  in  meningitis,  547  ;  in  mor- 
phinism, 318,  320;   in  myxcedema- 


INDEX 


607 


tous  alienation,  328,  329;  in  neu- 
rasthenia, 521 ;  in  paraldehyde  in- 
toxication, 316;  in  paranoia,  567, 
569,  570,  571 ;  in  paresis,  414, 
424,  439,  443,  447;  in  post-epi- 
leptic mental  disturbances,  480; 
in  psychasthenic  states,  531 ;  in 
senile  psychoses,  584,  592,  593, 
595,  596. 

Hallucinations,  Apperceptive,  59 ; 
Attention  in,  51 ;  Baillarger's  di- 
vision of,  59;  Bilateral,  63;  Ele- 
mentary, 59;  Elementary  audi- 
tory, 63 ;  Elementary,  of  light,  62 ; 
Erotic,  in  chorea,  222 ;  Idea- 
tional, 61 ;  of  hearing,  65 ;  of 
smell,  63 ;  of  taste,  in  delirium 
tremens,  293 ;  Peripheral  theory 
of,  62,  293 ;  Pseudo-,  59 ;  Psychic, 
59,  60;  Psychomotor,  in  cocain- 
ism,  323;  Psycho-sensorial,  59; 
Reflex,  66;  Stabile,  66;  Uni- 
lateral, 63,  424;  Ziehen's  theory 
explaining,   58. 

Hallucinatory,  confusion,  266;  de- 
lirium in  cerebral  syphilis,  458 ; 
disturbances,  315 ;  insanity,  208, 
266;  paranoiic  conditions  in  to- 
bacco intoxication,  324. 

Haptic  hallucinations,  in  chorea, 
222 ;  in  delirium  tremens,  292, 
293 ;  in  paranoia,  571 ;  in  pare- 
sis, 424,  443. 

Hebephrenia,  13,  372,  386,  569,  570. 

Hebephrenic  form  of  dementia  piae 
cox,  386. 

Heboidophrenia,    386. 

Henschen's  studies  in  the  pathology 
of  idiocy,  22. 

Hepatic  disease,  Mental  disturb- 
ances in,  217. 

Heredity,  121,  179,  541 ;  Atavistic, 
183 ;  in  dementia  precox,  404 ;  in 
epilepsy,  486;  in  manic-depres- 
sive insanity,  367 ;  in  paresis,  416 ; 
in  psychoses  associated  with  brain 
tumors,  549;  in  senile  dementia, 
597- 

Heteropia,  246. 

Heubner's,  endarteritis,  467 ;  group- 
ing of  syphilitic  psychoses,  559. 

Homicidal  impulse,  107 ;  in  epilepsy, 
474 ;   in  morphinism,  320. 

Hospitals  for  the  insane,  167. 

Hydrocephalus,  202,  241,  246. 

Hydrotherapy,  151  ;  in  acute  de- 
lirium, 265  ; '  in  alcoholism,  311; 
in  amentia,  274;  in  arterioscler- 
otic psychoses,  557 ;  in  epilepsy, 
491 ;     in    fever    deliria,    259 ;     in 


Graves'  disease,  335 ;  in  hysteria, 
514;  in  manic-depressive  insanity, 
370;  in  morphinism,  321;  in  pa- 
resis,   459;     in    senile    psychoses, 

591- 

Hyperacusis,  519. 

Hypersesthesia,  Acoustic,  60 ; 
Psychic,  117. 

Hyperesthesia  retine,  519. 

Hyperesthesias  in  hysteria,  495, 
496;  in  Korsakow's  syndrome, 
278;  in  morphinism,  318;  in  neu- 
rasthenic states,  519,  520;  in  pa- 
resis, 423. 

Hyperalgesias,  495,  496;  in  neuras- 
thenic states,  519. 

Hypermnesia,   82,   85. 

Hyperosmia,  519. 

Hyperprosexia,  51,  76;  in  maniacal 
phase  of  manic-depressive  insan- 
ity, 343- 

Hypertonia,  Muscular,  in  catatonic 
form  of  dementia  precox,  393, 
411. 

Hypervigility  of  the  attention,  51. 

Hypochondriacal  depression,  377. 

Hypochondriasis,  130,  131,  212,  221, 
370 ;  in  dementia  precox,  378, 
392,  397;  in  gout,  212;  in  manic- 
depressive  insanity,  352,  354,  359, 
368 ;  in  myxoedematous  aliena- 
tion, 329;  in  neurasthenic  states, 
521,  523 ;  in  paresis,  426,  427,  442, 
445,  448 ;  in  psychasthenic  states, 
523>  535  5  in  senile  psychoses,  578, 
580,  582,  584,  586,  593;  traumatic, 
203. 

Hypomania,  353,  355,  426. 

Hypomelancholia,   359. 

Hypovigility  of  the  attention,  50. 

Hysteria,  14,  63,  72,  84,  85,  97,  118, 
121,  131,  193,  196,  204,  221,  228, 
238,  363,  377,  385,  406,  433,  453, 
456,  474,  478,  482,  517,  526,  539, 
560;  Abulia  in,  495,  498,  503; 
Amnesia  in,  495,  497,  500;  Anaes- 
thesias in,  495,  496,  503,  51 1 ; 
Anxiety  in,  507,  508 ;  Associa- 
tion in,  504;  Attention  in,  495, 
496,  497,  500,  503 ;  Automatism 
in,  499 ;  Consciousness  in,  503, 
504,  506,  511;  Delirious  states  in, 
507;  Depression  in,  507,  508,  514; 
Differential  diagnosis  of,  510; 
Dissociation  in,  499,  500;  Dis- 
tractibility  in,  497 ;  Dream  states 
in,  503:  Emotions  in,  114,  494, 
495,  49.6,  5n;  Etiology  of,  509; 
Hallucinations  in,  496 ;  Hyper- 
esthesias in,  495,  496 ;    Illusions 


6o8 


INDEX 


in,  496;  Impulsivity  in,  106,  502; 
Insomnia  in,  514;  Irrelevancy  in, 
504,  510;  Mania  in,  507,  508; 
Memory  in,  498,  512;  Motor  dis- 
turbances in,  502 ;  Paraesthesias 
in,  495 ;  Phobias  in,  507 ;  Psychic 
abnormalities  of,  Grouping  of, 
494;  Sensory  disturbances  in, 
495,  502 ;  Sex  in,  509 ;  Somnam- 
bulism in,  506 ;  Speech  in,  504 ; 
Suggestibility  in,  503 ;  Suicidal 
impulses  in,  107;  Treatment  of, 
512;  Volitional  disturbances  in, 
498. 

Hysteria  Group,  494. 

Hysterical  hallucinatory  insanity, 
508. 

Hysterical  liars,  85,  428,  500. 

Hysterical  paranoioid  states,  508. 

Hysterical  seizures  in  migraine, 
221. 

Hysterical  states,  315,  530,  559. 

Hysterical  symptoms,  in  alcoholism, 
308 ;  following  apoplexy,  547 ; 
following  syphilitic  infection,  229 ; 
in   chorea,   223 ;     in   morphinism, 

317. 
Hysterie   douloureuse  a   manifesta- 
tion splanchnique,  509. 

Ideas,  53,  94;  Autochthonous,  142; 
Exaggerated,  102 ;  Exaggerated, 
in  dementia  praecox,  379. 

Ideas,  Fixed,  101,  496,  520,  579,  589. 

Ideas,  Flight  of,  see  Flight  of  ideas. 

Ideas,  Imperative,  see  Imperative 
ideas. 

Ideas,  Insane,  see  Insane  ideas. 

Ideas,  Levelling  off  of,  77,  126;  Ni- 
hilistic, in  senile  psychoses,  583 ; 
Obsessional,  529;  of  negation  in 
Korsakow's  syndrome,  280. 

Ideas  of  persecution,  45,  64;  in 
amentia,  269;  in  dementia  prae- 
cox,  397 ;  in  epilepsy,  483 ;  in 
Graves'  disease,  334;  in  Hunt- 
ington's chorea,  223 ;  in  hysteri- 
cal delirious  states,  508 ;  in  Kor- 
sakow's syndrome,  280;  in  myx- 
cedematous  alienation,  329;  in 
paranoia,  567 ;  in  paresis,  444 ; 
in  senile  psychoses,  582,  593,  595 ; 
in  syphilitic  psychoses,  561. 

Ideas  of  personality,  69,  569;  Anni- 
hilation of,  47. 

Ideas  of  reference,  132 ;  in  senile 
psychoses,  584. 

Ideas,  Systematization  of,  in  acute 
alcoholic  hallucinosis,  301 ;  in 
hysterical    delirious    states,    508  ; 


in  paranoia,  568,  570;  in  senile 
psychoses,  584,  589,  590,  594. 
Idiocy,  56,  92,  113,  116,  227,  229, 
230,  412,  482,  486 ;  Acquired,  372 ; 
Amaurotic  family,  245 ;  Anerge- 
tic  or  apathetic  form  of,  233 ; 
Associative  memory  in,  232,  233 ; 
Attention  in,  232,  234,  239 ;  Diag- 
nosis of,  248;  Dissociation  in, 
233  ;  Erethic  or  versatile  form  of, 
233 ;  Grouping  of,  230 ;  Impul- 
sivity in,  233 ;  Motor  anomalies 
in,  235 ;  Orientation  in,  232 ; 
Pathology  of,  22 ;  Physical  mani- 
festations in,  234 ;  Speech  in,  232 ; 
Sensations  in,  233,  234;    Tics  in, 

95- 

Illusions,  57,  58,  59,  67,  92,  257,  268, 
269 ;  in  amentia,  407 ;  in  demen- 
tia praecox,  381,  386;  in  hysteria, 
496;  in  manic-depressive  insan- 
ity,. 342- 

Imagination,  60. 

Imbecile  children  in  schools,  239. 

Imbecilitas  tarda,  372. 

Imbecility,  56,  92,  113,  227,  229,  230, 
235,  408,  412,  486;    Etiology  of, 

239- 

Imitation  and  suggestion,  190. 

Imperative  ideas,  95,  100,  102,  112, 
132;  in  dementia  praecox,  379; 
in  epilepsy,  476;  in  manic-depres- 
sive insanity,  351 ;  in  psychas- 
thenic states,  524. 

Imperative  process  psychoses,  101. 

Impulses,  92,  98,  112,  121,  228;  Sex- 
ual, 108. 

Impulsive  insanity,  228. 

Impulsivity,  97,  104,  106,  121,  125,' 
196,  315,  386,  483,  559;.  in  apo- 
plexy, 546;  in  dementia  para- 
noides, 399;  in  dementia  praecox, 
369,  377,  392,  395,  397,  400,  406, 
408 ;  in  epilepsy,  407,  474,  477, 
478,  480,  481 ;  in  hysteria,  106,  502  ; 
in  idiocy,  233 ;  in  manic-depres- 
sive insanity,  106;  in  neuras- 
thenia, 516;  in  senile  psychoses, 
593,  596. 

Infantilism  and  tuberculosis,  243. 

Infantilism,  Non-myxoedematous, 
242. 

Influenza,  255,  256,  258,  262,  274, 
376.  387- 

Inhibition,  44,  115,  340;  in  alco- 
holism, 286 ;  in  bromism,  323  ;  in 
epilepsy,  475 ;  in  dementia  prae- 
cox, 386,  394,  400;  in  manic-de- 
pressive insanity,  343,  352,  369. 

Initial  delirium,  256. 


INDEX 


609 


Insane  ideas,  36,  61,  95,  97,  119,  132, 
137,  140,  142,  210,  483,  541 ;  and 
anomalies  in  organic  sensations, 
44;  in  alcoholic  paranoiic  states, 
306;  in  arteriosclerotic  psycho- 
ses, 553»*  in  cerebral  syphilis, 
458;  in  dementia  paranoides,  399 ; 
in  dementia  praecox,  378,  381,  396, 
397;  in  epilepsy,  477;  in  hepatic 
disease,  217;  in  manic-depressive 
insanity,  352,  354,  522;  in  myx- 
cedematous  alienation,  328;  in 
paranoia,  567,  569,  570,  571;  in 
paresis,  427,  443,  446,  447;  in 
senile  psychoses,  584,  585,  589, 
593,  596. 

Insanity,  Conjugal,  191,  193;  Gen- 
eral causes  of,  178 ;  Induced,  192 ; 
of  puberty  and  adolescence,  372; 
of  pubescence,  372 ;  Nuptial,  205 ; 
Pathogenesis  of,  7. 

Insight,  following  apoplexy,  547; 
in  arteriosclerotic  psychoses,  553 ; 
in  delirium  tremens,  297;  in  epi- 
lepsy, 477;  in  multiple  sclerosis, 
544,  545 ;  in  neurasthenic  states, 
540 ;  in  paresis,  442,  445 ;  in  psy- 
chasthenic states,  455 ;  in  senile 
psychoses,  582;  in  syphilitic  psy- 
choses, 560. 

Insomnia,  in  alcoholism,  290;  in 
arteriosclerotic  psychoses,  557 ; 
in  cocainism,  322;  in  dementia 
praecox,  388;  in  hysteria,  514;  in 
manic-depressive  insanity,  354 ; 
in  neurasthenia,  525 ;  in  paralde- 
hyde intoxication,  317;  in  pare- 
sis, 439,  459;  in  senile  psychoses, 
588. 

Instability  in  neurasthenia,  516. 

Insufficiency,  Feeling  or  Sense  of, 
123 ;  in  manic-depressive  insan- 
ity, 3Si,  352,  354,  369;  in  senile 
psychoses,  579,  589. 

Intellect,  12;  Defects  of,  26;  in 
chorea,  222 ;  in  dementia  prae- 
cox,  376,  380;  in  epilepsy,  475: 
in  Huntington's  chorea,  223. 

Intoxication,  Ether,  314;  Paralde- 
hyde, 316;    Tobacco,  323. 

Intoxications,  Drug,  188,  227;  Fear 
in,  118;  Psychoses  the  result  of 
chronic,  285. 

Intrapsychic  incoordination  in  de- 
mentia praecox,  114. 

Irrelevancy,  140;  in  dementia  prse- 
cox,  368,  383,  389,  390,  510;  in 
hysteria,  504;  in  hysterical  dis- 
turbances of  consciousness  fol- 
lowing trauma,  511. 


Irritability,  131 ;  associated  with 
brain  abscess,  548 ;  associated  with 
brain  tumors,  549;  in  anaemia, 
208;  in  apoplexy,  546;  in  arterio- 
sclerotic psychoses,  552;  in 
chorea,  222;  in  cocainism,  322; 
in  dementia  prsecox,  387 ;  in  epi- 
lepsy, 477;  in  manic-depressive 
insanity,  365 ;  in  melancholia, 
523;  in  morphinism,  318,  320;  in 
multiple  sclerosis,  544 ;  in  neuras- 
thenic states,  521 ;  in  paranoia, 
571 ;  in  paresis,  425,  439,  443 ;  in 
senile  psychoses,  593,  595. 

Isolation,  as  a  cause  of  insanity, 
157;  in  the  treatment  of  insanity, 
157- 

Judgment,  7,  26,  60,  123,  541 ;  in 
alcoholic  paranoiic  states,  304;  in 
hypomania,  357,  358;  in  mental 
debility,  238 ;  in  myxoedematous 
alienation,  327;  in  paranoia,  567; 
in  paresis,  426. 

Kleptomania,   107. 

Korsakow's  syndrome,  56,  85,  220, 
227,  277,  419,  457,  592;  Clinical 
forms  of,  279;  Differential  diag- 
nosis of,  282;  Duration  of,  280; 
Etiology  of,  281 ;  Pathology  of, 
283 ;    Treatment  of,  282. 

Kraepelin's,  division  of  febrile  de- 
liria,  258;  method  of  investiga- 
tion, 13. 

Krishaber's  work  on  organic  sensa- 
tions, 32. 

Larvirte  epilepsie,  477. 

Lead    poisoning,    324;     in    paresis, 

4J9- 

Leptomeningitis,  202 ;  chronica  pro- 
funda in  paresis,  462. 

Lie,  Tendency  to,  368;  in  hysteria, 
500;    in  morphinism,  317. 

Litigious  insanity,  397,  571. 

Localization,  Cortical,  20. 

Lucid  intervals,  in  dementia  prae- 
cox,  400;  in  Huntington's  chorea, 
223 ;  in  hysterical  dream  states, 
506;  in  manic-depressive  insanity, 
353,  36i,  364. 

Macropsia,  497. 

Malaria,  130;  as  a  cause  of  non- 
myxoedematous  infantilism,  243. 

Mania,  206,  336,  363,  364,  372,  509, 
564;  Attention  in,  51;  Delirious, 
266;  Epileptic,  369,  478;  gravis, 
355;    Hysterical,    507,    508,    511; 


39 


6io 


INDEX 


mitissima,  355;  Mood  in,  112; 
Psychoanalgesia  in,  115;  Psycho- 
motor excitability  in,  93  ;  Recur- 
rent, 353  ;  Unproductive,  355,  358 ; 
Wandering,  47,  132,  196;  without 
delirium,   119,  354. 

Manic-depressive  group,  336. 

Manic-depressive  insanity,  14,  32, 
38,  44,  76,  119,  135,  195,  204,  205, 
216,  221,  227,  229,  256,  260,  266, 
274,  282,  329,  334,  380,  393,  401, 
406,  425,  440,  453,  458,  468,  478, 
484,  492,  508,  511,  539,  549,  56o, 
566,  590,  597 ;  Clinical  course  of, 
353 ;  Differential  diagnosis  of, 
368 ;  Dissociation  in,  75 ;  Eti- 
ology of,  362;  Gastro-intestinal 
disturbances  in,  349,  540;  Group- 
ing of  forms  of,  353  ;  Heredity  in, 
367;  Impulsivity  in,  106;  Initial 
stage  of,  354;  Insane  ideas  in, 
522 ;  Irritability  in,  365 ;  Memory 
defects  in,  85  ;  Mortality  in,  355  ; 
Pathogenesis  of,  367;  Pathology 
of,  371 ;  Prognosis  in,  364 ;  Psy- 
chomotor retardation  in,  359,  360, 
362,  365,  368,  511;  Second  stage 
of,  355;  Terminal  stage  of,  355; 
Treatment  of,  369;  Weight  in, 
348,  365,  540. 

Manic-depressive  insanity,  Depres- 
sive phase  of,  349,  354;  Akinesis 
in,  351 ;  Anxiety  in,  351,  354,  355 ; 
Apprehension  in,  351 ;  Associa- 
tion in,  351,  354,  355;  Blood- 
pressure  in,  345,  351,  371 ;  Con- 
fusion in,  351 ;  Dissociation  in, 
352;  Emotion  in,  350,  351,  354; 
Feeling  of  insufficiency  in,  351, 
352 ;  Hallucinations  in,  352 ;  Hy- 
pochondriasis in,  352,  354,  359, 
368;  Imperative  ideas  in,  351; 
Inhibition  in,  352 ;  Insane  ideas 
in,  352,  354;  Insomnia  in,  354; 
Micromania  in,  351 ;  Motor  anom- 
alies in,  350,  354,  355;  Obses- 
sional impulses  in,  352 ;  Orienta- 
tion in,  351 ;  Physical  symptoms 
of,  353 ;  Pulse  in,  351 ;  Pupils  in, 
349 ;  Psychomotor  retardation 
in,  350,  353-  354 ;  .  Reaction  time 
in,  350 ;  Reflexes  in,  349 ;  Soma- 
topsychic consciousness  in,  351 ; 
Speech  in,  350;  Stupor  in,  87, 
352;  Writing  in,  351. 

Manic-depressive  insanity,  Maniacal 
phase  of,  338 ;  Absence  of  fatigue 
in,  344 ;  Association  in,  342,  343 ; 
Attention  in,  342,  343 ;  Blood  in, 
346;    Blood-pressure  in,  345,  371; 


Bulimia  in,  349;  Consciousness 
in,  343  5  Dermatographia  in,  216; 
Emotional  anomalies  in,  344; 
Facial  expression  in,  341 ;  Flight 
of  ideas  in,  340,  355,  368,  408,  511 ; 
Gastro-intestinal  disturbances  in, 
354 ;  Hallucinations  in,  342 ;  Hy- 
perprosexia  in,  343 ;  Illusions  in, 
342 ;  Inhibition  in,  343 ;  Motor 
symptoms  of,  117,  338,  339;  Mus- 
cular power  in,  340;  Orientation 
in,  343  ;  Pain  sense  in,  340 ;  Phy- 
sical symptoms  of,  345  ;  Pulse  in, 
ii7,  345,  346,  356,  357;  Pupils 
in,  349 ;  Reflexes  in,  349 ;  Respira- 
tion in,  346 ;  Sensations  in,  342, 
344 ;  Sexual  excitement  in,  345 ; 
Speech  compulsion  in,  75,  340; 
Temperature  in,  348;  Tremor  in, 
117,  339;  Urine  in,  348;  Weight 
in,  348;    Writing  in,  341. 

Mannerisms,  250,  274,  485 ;  in  de- 
mentia praecox,  369,  386,  396,  397, 
400,  404,  405,  406,  510. 

Marriage,  147,  184,  205. 

Martyrs,  116. 

Masochismus,   108. 

Massage,  153. 

Medicinal  therapy,  161. 

Medullation,  in  the  nerves,  19;  of 
nerve  tracts,  20. 

Megalomania,  47,  64 ;  in  acute  alco- 
holic hallucinosis,  301 ;  in  arterio- 
sclerotic psychoses,  553 ;  in  de- 
lirium tremens,  295  ;  in  dementia 
paranoides,  397,  398;  in  dementia 
praecox,  378 ;  in  paresis,  439,  440, 
446. 

Melancholia,  see  also  Depression, 
and  Manic-depressive  insanity, 
Depressive  phase  of, 

Melancholia,  36,  105,  119,  206,  279, 
336,  363,  364,  372,  522,  535,  564, 
588 ;  agitata,  360,  592 ;  Involu- 
tional, 360,  369,  590,  593;  Recur- 
rent, 353 ;  Senile,  216,  407,  578. 

Memories,  Sense,  in  imbecility,  235 ; 
in  neurasthenic  states,  520. 

Memory,  27,  53,  55,  69,  81,  91,  104, 
132 ;  in  alcoholic  paranoiic  states, 
304  ;  in  amentia,  267 ;  in  arterio- 
sclerotic psychoses,  552,  553 ;  in 
chorea,  222 ;  in  delirium  tremens, 
294 ;  in  dementia  praecox,  378,  388, 
389,  394;  in  epilepsy,  475,  479, 
482 ;  in  Huntington's  chorea,  223  ; 
in  hysteria,  498,  512;  in  paranoia, 
569,  570,  571 ;  in  paresis,  85,  420, 
427,  454,  458 ;  in  senile  psychoses, 
575 ;    in  syphilitic  psychoses,  561. 


INDEX 


6n 


Memory,  Abnormal,  in  mental  de- 
bility, 237. 

Memory,  Associative,  see  also  Asso- 
ciation. 

Memory,  Associative,  27,  28,  31,  52, 
58,  68,  82,  87,  141,  266;  in  amen- 
tia, 267 ;  in  apoplexy,  546,  547 ; 
in  cretinism,  331 ;  in  dementia 
praecox,  397 ;  in  epilepsy,  475  ;  in 
fatigue,  199 ;  in  idiocy,  232,  233 ; 
in  imbecility,  235 ;  in  Korsakow's 
syndrome,  277,  278,  279,  282 ;  in 
mental  debility,  237;  in  migraine, 
222 ;  in  multiple  sclerosis,  545 ; 
in  myxoedematous  alienation,  327; 
in  paranoia,  571 ;  in  pseudo- 
paresis,  214 ;  in  senescence,  575  ; 
in  senile  psychoses,  585,  588,  595. 

"  Memory  Cramps,"   102. 

Memory,  Detention,  84;  Develop- 
ment of,  83 ;  Division  of  func- 
tions of,  82 ;  Muscular,  83 ;  Re- 
tention, 83. 

Memory  pictures,  88,  91,  109. 

Meningitis,  130,  225,  241,  258,  280, 
368,  436,  492 ;  Psychoses  asso- 
ciated with,  547. 

Mental  anomalies  the  result  of  de- 
fective development,  230. 

Mental  capabilities,  Importance  of 
determination  of,  7. 

Mental  debility  or  enfeeblement, 
230,  237 ;    Apathetic  type  of,  238. 

Mental  development,  Preyer's  table 
indicating  normal,  248. 

Mental  diseases,  Grouping  of,  225. 

Mental  disorders,  associated  with 
cardiac  and  vascular  disease,  215 ; 
with  chorea,  222 ;  with  anomalies 
in  the  function  of  the  thyroid 
gland,  326 ;  with  gastro-intestinal 
disturbances,  220 ;  with  hepatic 
disease,  217 ;  with  hyperfunction 
of  the  thyroid  gland,  333 ;  with 
migraine,  221 ;  with  nephritis, 
219;  with  operations  upon  the 
common  bile-duct,  218;  Treat- 
ment of,  335. 

Mental  processes  in  children  and 
primitive  peoples,  29. 

Mental  rumination,  123,  542. 

Mental  treatment,  155. 

Merkfdhigkeit,  50,  82. 

Metabolism,  Defective,  in  relation 
to  mental  disease,  211. 

Microcephalus,  202,  247 ;  Operative 
interference  in,  252. 

Microgyria,  245. 

Micromania,  48 ;  in  manic-depres- 
sive insanity,  351. 


Micropsia,  497. 

Migraine,  Mental  disorders  asso- 
ciated with,  221. 

Migrainous  epilepsy,  221. 

Mimic-cramp   neurosis,   97. 

Mirror  writing  in  dementia  praecox, 
383. 

Monomania,  Affective,  119;  In- 
stinctive, 119. 

Monsters,  244. 

Mood,  112,  113,  117,  569. 

Moral  insanity,  119,  125,  239. 

Moral  sense,  119;  in  arteriosclero- 
tic psychoses,  553 ;  in  paresis,  426, 
454- 

Morphinism,  10,  317,  530;  Physical 
symptoms  of,  318;  Treatment  of, 
320. 

Motor  anomalies,  in  acute  delirium, 
262,  263 ;  in  chorea  gravidarum, 
223  '■>  in  dementia  praecox,  369,  386, 
391 ;  in  hysteria,  502 ;  in  idiocy, 
235  ;  in  manic-depressive  insanity, 
338,  339,  350,  354 ;  in  paresis,  428, 
431 ;    in  senescence,  576. 

Motor  restlessness,  210,  213,  258, 
265,  349,  353,  359,  362,  363,  364, 
365,  368,  483,  484 ;  associated  with 
brain  abscess,  548 ;  in  alcoholism, 
286;  in  amentia,  267,  268,  269;  In 
arteriosclerotic  psychoses,  554;  in 
chorea,  222 ;  in  delirium  tremens, 
291,  295,  297;  in  epilepsy,  477, 
478;  in  hypomania,  357;  in  manic- 
depressive  insanity,  355  ;  in  mor- 
phinism, 318;  in  paresis,  446;  in 
psychasthenic  states,  533 ;  in 
senile  psychoses,  586,  589,  591, 
592,  596. 

Multiple  sclerosis,  456,  544. 

Muscle  sense,  28,  29,  87. 

Muscles,  Electrical  response  of,  in 
paresis,  429 ;  Exaggeration  of 
functional  power  of,  in  manic- 
depressive  insanity,  340;  Inco- 
ordination of,  in  paresis,  428,  451, 
452 ;  Mechanical  irritability  of, 
in  dementia  prsecox,  402,  411; 
Mechanical  irritability  of,  in 
senile  psychoses,  589;  Power  of, 
in    the    neurasthenic    states,    519, 

538- 

Muscular  rigidity  in  catatonic  form 
of  dementia  praecox,  393. 

Mutism,  139;  in  dementia  prsecox, 
391 ;  in  epileptic  mania,  478,  480  ; 
in  imbecility,  237 ;  in  unproduc- 
tive mania,  355. 

Mysophobia,  527. 

Mysticism,   398. 


6l2 


INDEX 


Myxoedema,  18,  326,  402 ;  Physical 
symptoms  of,  326 ;  Treatment  of, 
329. 

Myxoedematous  alienation,  327. 

Myxoedematous  infantilism  differ- 
entiated from  non-myxoedematous 
infantilism,  243. 

Nanocephalus,  247. 

Narcolepsy,  213. 

Negativism,  97,  138,  385;  in  de- 
mentia prsecox,  381,  386,  389,  391, 
396,  400,  407,  485,  510;  in  myxoe- 
dematous alienation,  328. 

Nekrophilia,  108. 

Nephritis,  62,  129,  552,  590,  597; 
Mental  disorders  associated  with, 
219. 

Nerve-cell  changes  in  acute  de- 
lirium, 275;  in  alcoholism,  314; 
in  amentia,  275 ;  in  chloroform 
psychoses,  315  ;  in  cretinism,  333  ; 
in  defect  psychoses,  246,  247 ;  in 
delirious  mania,  371 ;  in  dementia 
praecox,  410;  in  paresis,  464;  in 
senescence,  577. 

Nerve-cells,  Effect  of  fatigue  on, 
200 ;  Fever-change  in,  260 ;  Sig- 
nificance of  pathological  changes 
in,  21. 

Nerve-fibres,  19,  20,  261 ;  Signifi- 
cance of  pathological  changes  in, 
22. 

Nervous  system,  Blood  and  lymph 
channels  of  the  central,  21 ;  in 
senescence,  576;  Mental  symp- 
toms associated  with  organic 
changes  in  the,  544;  Pathology 
of,  18. 

Neurasthenia,  63,  71,  72,  118,  123, 
228,  356,  359.  377,  406,  433.  ^7. 
454,  510,  516,  518,  560;  see  also 
Neurasthenic  states. 

Neurasthenic  states,  369,  516,  518, 
559;  Apprehensiveness  in,  516; 
Attention  in,  51,  519,  521  ;  Char- 
acteristics of,  516;  Depression  in, 
516,  522,  523;  Differential  diag- 
nosis of,  538 ;  Distractibility  in, 
521;  Emotional  anomalies  in,  114, 
115,  521,  523;  Etiology  of,  541; 
Fatigue  in,  516,  518,  519,  538; 
Hallucinations  in,  521 ;  Hypo- 
chondriasis in,  521,  523 ;  Im- 
pulsivity  in,  516 ;  Insight  in, 
540 ;  Insomnia  in,  525 ;  Irritabil- 
ity in,  521 ;  Paresthesias  in,  521 ; 
Phobias  in,  516;  Physical  symp- 
toms of,  536 ;  Sensory  disturb- 
ances in,  519;    Treatment  of,  541. 


Neurasthenic      and      psychasthenic 

states,  516. 
Nenrocerebrite  toxique,  277. 
Neuronophagia  in  paresis,  466. 

Obsessions,  100,  103,  121,  455,  517, 
529 ;  Grouping  of,  105 ;  in  chorea, 
222;  in  epilepsy,  476  477,  478, 
480 ;  in  manic-depressive  insanity, 
352;  in  neurasthenia,  516;  in  psy- 
chasthenic states,  523,  534,  535, 
536. 

Onomatomania,  525. 

Operations,  Psychoses  developing 
after,  204. 

Organic  brain  diseases,  75,  227. 

Orientation,  see  also  Disorientation. 

Orientation,  86,  141 ;  in  acute  alco- 
holic hallucinosis,  302;  in  de- 
lirium tremens,  294 ;  in  dementia 
prsecox,  381,  389,  390 ;  in  epileptic 
mania,  478 ;  in  idiocy,  232 ;  in 
manic-depressive  insanity,  343, 
351;  in  multiple  sclerosis,  545;  in 
paraldehyde  intoxication,  317;  in 
paresis,  87,  421,  439,  446;  in  psy- 
chasthenic states,  532 ;  in  senile 
psychoses,  585,  593,  595. 

Osteogenesis  imperfecta  of  the 
newborn,  244. 

Out-door  patients,  177. 

Pachymeningitis  chronica,  202 ;  in 
paresis,  461. 

Paederasty,  108. 

Pain,  53,  109,  130,  131,  233,  393,  495, 
496,  519,  543;  in  neurasthenia, 
62. 

Pain  sense  in  maniacal  phase  of 
manic-depressive  insanity,  340 ;  in 
paresis,  423. 

Paradoxical  light  reflex,  433. 

Paresthesia,  67,  no;  in  alcoholic 
paranoiic  states,  305  ;  in  dementia 
prsecox,  2>77<  382,  388 ;  in  hysteria, 
495 ;  in  Korsakow's  syndrome, 
278 ;  in  lead  poisoning,  325 ;  in 
migraine,  221 ;  in  morphinism, 
318;  in  neurasthenic  states,  521. 

Parageusias,  63. 

Paraldehyde,  Intoxication  from, 
316. 

Paralexia,  67 ;  in  delirium  tremens, 
294. 

Paralogia,  383. 

Paramnesia,  82,  85. 

Paranoia,  105,  228,  229,  396,  397, 
564 ;  Acute  alcoholic,  300 ; 
Chronic  hallucinatory,  570;   Orig- 


INDEX 


613 


inal,  568,  569;    Pathogenesis  of, 
566,  569- 
Paranoia,     dissociativa,    266 ;      Re- 
current,  353,   361 ;     rudimentaria, 

Paranoiic  form  of  dementia  prse- 
cox,  396. 

Paranoiic  states,  12,  193,  204,  353, 
444,  482,  508,  517;  and  dementing 
states  developing  during  chronic 
alcoholism,  304;  after  amentia, 
270;  following  fever  deliria,  259; 
in  epilepsy,  482 ;  in  manic-de- 
pressive insanity,  566,  568. 

Parapraxia,  139. 

Paratonia  progressiva,  372,  411. 

Paresis,  22,  23,  24,  75,  186,  209,  229, 
279,  295,  407,  413,  512,  540,  556, 
561,  591;  Acute,  438,  453;  Alco- 
holism in,  418 ;  Amnesias  in,  420 ; 
Amyloid  bodies  in,  466;  Amyo- 
tropic  forms  of,  449;  Anxiety  in, 
425,  443 ;   Apathy  in,  414,  425,  445, 

448,  455,   457;     Aphasia   in,   421, 

449,  452,  456;  Apprehensiveness 
in,  425,  443,  445;  Argyll-Robert- 
son pupil  in,  250,  409,  433,  458 ; 
Arteriosclerotic  changes  in,  469; 
Arthropathies  in,  435 ;  Associa- 
tion in,  420,  422 ;  Ataxia  in,  440 ; 
Attention  in,  420,  443,  448,  454; 
Atypical  cases  of,  449;  Brain 
weight  in,  462 ;  Cardiac  disturb- 
ances in,  436;  Catatonic  symp- 
toms in,  409,  430;  Cerebellar 
form  of,  450;  Clinical  forms  of, 
438;  Conjugal,  418;  Conscious- 
ness in,  426,  451,  452,  456;  Cor- 
tical atrophy  in,  463 ;  Course  of, 
437 1  Cyanosis  in,  435  ;  Cytodiag- 
nosis  in,  455;  Daily  life  and,  419; 
Delusions  in,  414,  446,  447;  De- 
mentia in,  438,  443,  444,  446,  449; 
Dementing  form  of,  448,  453; 
Depression  in,  414,  425,  427,  431, 
436,  439,  440,  444,  446;  Differ- 
ential diagnosis  of,  454;  Dissocia- 
tion in,  423,  427 ;  Dissolution  of 
the  personality  in,  70;  Distracti- 
bility  in,  420,  422,  440,  444,  448; 
Dural  changes  in,  461 ;  Emo- 
tional anomalies  in,  425,  427,  439, 
455 ;  Ependymal  changes  in,  462 ; 
Etiology  of,  416;  Euphoria  in, 
368,  388,  423,  427,  430 ;  Exaltation 
in,  425,  439;  Excitement  in,  414, 
436,  439,  444,  446;  Exhibitionism 
in,  108,  427  ;  Facial  asymmetry  in, 
431,  440;  Fatigue  in,  418,  424, 
446,  458;    Febrile  disturbances  in, 


436 ;  Fibre  changes  in,  463 ;  Final 
stages  of,  438 ;  First  period  of, 
437;  Flight  of  ideas  in,  440; 
Focal  symptoms  in,  468 ;  Gait  in, 
429;  Galloping,  438;  Gastro-in- 
testinal  disturbances  in,  419,  436, 
437>  454;  Glia  changes  in,  465; 
Hsematomata  in,  462 ;  Hallu- 
cinations in,  414,  424,  439;  He- 
redity in,  416;  Hydrotherapy  in, 
459 ;  Hypassthesias  in,  423 ;  Hy- 
peresthesias in,  423 ;  Hypochon- 
driasis in,  426,  427,  442,  445,  448 ; 
Ideas  of  persecution  in,  444;  In- 
cidence of,  415 ;  Inco-ordinatioh 
of  muscles  in,  428 ;  Insane  ideas 
in,  427,  446,  447 ;  Insight  in,  442, 
445;  Insolation  in,  419;  Insom- 
nia in,  439,  459;  Irritability  in, 
425,,  439 ;  Judgment  in,  426 ;  Ju- 
venile, 562;  Lead  poisoning  in, 
419;  Megalomania  in,  439,  440, 
446 ;  Memory  in,  85,  420,  427,  454, 
458;  Mental  symptoms  of,  420; 
Migraine  in,  443  ;  Moral  sense  in, 
426,  454;  Motility,  Disturbances 
of,  428,  431 ;  Muscular  disturb- 
ances in,  428,  455 ;  Nerve-cell 
changes  in,  464 ;  Neuronopha- 
gia  in,  466;  Optic  atrophy  in, 
433;  Orientation  in,  87,  421,  439, 
446 ;  Pain  sense  in,  423 ;  Patho- 
logical anatomy  of,  460,  470; 
Personality  in,  426;  Pial  changes 
in,  462;  Plasma  cells  in,  467; 
Prodromal  stage  of,  437;  Psycho- 
anaesthesias  in,  423 ;  Psycho- 
hypassthesias  in,  423 ;  Psycho- 
hyperaesthesias  in,  423 ;  Pupils  in, 
407,  433,  455;  Reflexes  in,  434, 
452 ;  Remissions  in,  440,  444,  447, 
452,  460 ;  Respiration  in,  436 ; 
Rod  cells  in,  471 ;  Saline  in- 
fusions in,  459,  460 ;  Second 
period  of,  438;  Seizures  in,  451; 
Sensation  in,  420,  423,  446,  448 ; 
Sense  of  duty  in,  426,  448;  Sense 
of  power  in,  447;  Sense  of  pro- 
portion in,  426;  Sense  of  well- 
being  in,  447;  Sexual  irregulari- 
ties in,  427,  459;  Skull  changes 
in,  461  ;  Social  position  and,  419; 
Somatic  symptoms  of,  428,  440 ; 
Spastic  forms  of,  449;  Speech  in, 
250,  407,  409,  413,  430,  451,  452, 
455,  458 :  Stereometric  sense  in, 
427 ;  Stigmata  of  degeneration 
in,  416;  Stupor  in,  444,  451 ;  Sus- 
piciousness in,  444;  Sweating  in, 
435  ;  Sympathetic,  Changes  in  the, 


614 


INDEX 


in,  466;  Syphilis  in,  417;  Tabes 
and,  450;  Tabetic  forms,  449; 
Termination  of,  453 ;  Trauma  in, 
418,  425;  Treatment  of,  458; 
Tremor  in,  428,  446,  452 ;  Trigem- 
inus symptom  in,  452 ;  Trophic 
disturbances  in,  435,  454;  Urine 
in,  436,  437 ;  Vascular  changes  in, 
24,  467;  Vasomotor  disturbances 
in,  435  ;  Visceral  changes  in,  461 ; 
Visual  disturbances  in,  432; 
Volition  in,  93 ;  Weight  in,  436 ; 
Writing  in,  431. 
Paresis,  Depressed  form  of,  442; 
Attention  in,  443 ;  Hallucina- 
tions in,  443 ;  Insane  ideas  in, 
443 ;  Irritability  in,  443 ;  Motor- 
restlessness  in,  443 ;  Suicidal  ten- 
dencies in,  445. 

Paresis,  Expansive  form  of,  427, 
431,  445,  453 ;  Course  of,  447 ;  Ex- 
hilaration in,  445 ;  Hallucinations 
in,  447 ;  Insight  in,  445 ;  Motor 
restlessness  in,  446. 

Paretic  marasmus,  453. 

Parturition,  262,  368. 

Passive  movements,  Resistance  to, 
in  catatonic  form  of  dementia 
prsecox,  393. 

Pathology  of  central  nervous  sys- 
tem, 18;  in  multiple  sclerosis,  545. 

Perception,  100 ;  in  amentia,  407 ; 
in  delirium  tremens,  294;  in 
Korsakow's  syndrome,  279. 

Periodic  insanity,  360;  Prognosis 
in,  364. 

Perseveration,  99,  485 ;  in  epileptic 
dream  states,  479. 

Personality,  12 ;  Anomalies  of,  32 ; 
Anomalies  of,  in  paresis,  426; 
Double,  532. 

Pessimism,  122,  131,  132. 

Petit  mal  intellectuel,  477. 

Phobias,  228,  455  ;  in  epilepsy,  475 ; 
in  Graves'  disease,  333,  334 ;  in 
hysteria,  507  ;  in  Korsakow's  syn- 
drome, 280;  in  neurasthenia,  516; 
in  non-myxcedematous  infantil- 
ism, 243  ;  in  psychasthenic  states, 
526,  529,  534. 

Photomata,   59. 

Photophobia,   519,   527. 

Phrenomania,  261. 

Plasma  cells  in  paresis,  467. 

Pleasure,  53,  232,  233,  543,  579. 

Pneumonia,  130,  256,  258,  262,  270, 
298,  355,.  436,  440,  453,  590,  597- 

Polyneuritic  psychoses,  86,  277. 

Porencephalus,  202,  246. 

Poromania,  70,   196,  474. 


Post-febrile  psychoses,   260. 
Pregnancy  and  parturition  as  causes 

of  insanity,  206,  487. 
Presbyophrenia,  592. 
Presenile      Beeintrachtigungswahn, 

593- 

Progressive  general  paralysis  of  the 
insane,  413. 

Pseudo-hallucinations  in  dementia 
prsecox,  378. 

Pseudo-microcephalus,  247. 

Pseudo-paresis,  of  diabetic  origin, 
214,  434,  437;  of  syphilitic  origin, 
561. 

Pseudo-reminiscences,  85,  137,  141 ; 
in  chloroform  psychoses,  315;  in 
Korsakow's  syndrome,  277,  278, 
280. 

Psychsesthesias  in  morphinism,  318. 

Psychasthenia,  188,  222,  228,  438,  455, 
516. 

Psychasthenic  states,  228,  437,  523 ; 
Apprehensiveness  in,  533,  536; 
Cause  of,  533 ;  Consciousness  in, 
532 ;  Course  of,  534 ;  Depression 
in,  530 ;  Emotional  disturbances 
in,  526,  529,  540;  Hallucinations 
in,  531 ;  Imperative  ideas  in,  524; 
Insight  in,  455 ;  Intermittent 
form  of,  534;  Motor  restless- 
ness in,  533 ;  Obsessions  in, 
523.  535;  Orientation  in,  532; 
Phobias  in,  526,  529,  534 ;  Prog- 
nosis in  episodic  forms  of,  535 ; 
Remittent  forms  of,  535 ;  Ter- 
mination of,  535 ;  Tics  in,  526 ; 
Tremor   in,   529. 

Psychiatrical  hospitals,  146,  167. 

Psychiatry,  in  relation  to  physi- 
ology, 3 ;  in  relation  to  psychol- 
ogy, 5 ',  Scope  and  methods  of, 
1 ;  Work  of  the  French  school 
in,  14. 

Psychic    anaesthesias,    36,    258,    262, 

495,.  5"- 

Psychic  antagonism,  Law  of,  343. 

Psychic  epilepsy,  473. 

Psychic  hallucinations,  in  dementia 
prsecox,  ^77 ',  in  manic-depressive 
insanity,  342  ;  in  paresis,  443  :  in 
senile  psychoses,  584. 

Psychic  hyperesthesias,  258,  262, 
263,  495,  496,  519,  526,  553. 

Psychic  paraesthesias,  258,  262,  495. 

Psychic  phenomena,  Methods  of 
investigating,   3. 

Psycho-algia,  56. 

Psycho-anaesthesia,  56 ;  in  demen- 
tia prsecox,  377,  395 ;  in  paresis, 
423- 


INDEX 


615 


Psycho-analgesia  in  fanatics  and 
martyrs,  116;  in  maniacal  pa- 
tients, 115. 

Psycho-hypaesthesia,  98;    in  paresis, 

423. 

Psycho-hyperaesthesia,  56. 

Psychomotor  excitability,  44,  00, 
93;  in  hepatic  disease,  217;  in 
manic-depressive   insanity,   339. 

Psychomotor  hallucinations  in  pa- 
resis, 424. 

Psychomotor  inhibition,  77. 

Psychomotor  irritability,  75,  78,  99. 

Psychomotor  retardation,  90,  93, 
97,  98,  140,  369;  in  anaemia,  209; 
in  epilepsy,  480;  in  manic-de- 
pressive insanity,  350,  353,  354, 
359,  360,  362,  365,  368,  51 1. 

Psycho-pathology,  Functions  of,  7. 

Psycho-physic  parallelism,  Theory 
of,  4. 

Puberty,    193,    273,    370,    373,    374, 

387. 

Pulse,  in  cocainism,  322 ;  in  de- 
lirium tremens,  296;  in  demen- 
tia praecox,  402 ;  in  fear,  109 ;  in 
manic-depressive  insanity,  117, 
345,  346,  351,  356,  357;  in  myx- 
cedema,  327;  in  neurasthenic 
states,  538;  in  paretic  seizures, 
451 ;    in   senile  psychoses,   588. 

Pupils,  in  alcoholism,  289;  in  co- 
cainism, 322 ;  in  dementia  prae- 
cox, 402 ;  in  manic-depressive 
insanity,  349 ;  in  migraine,  221 ; 
in  morphinism,  319;  in  paresis, 
407,  433,  455 ;  in  senescence,  576, 
597-. 

Pyrexia,  Effects  of,  on  nerve-cells, 
260,  276. 

Pyromania,  107,  474. 

Reaction  time  in  manic-depressive 
insanity,  350. 

Recognition  faculty,  83. 

Recording  faculty,  50,  82. 

Reflex  acts,  and  the  associative  ac- 
tivities of  the  brain,  52. 

Reflex  movements,  90. 

Reflexes,  in  amentia,  269;  in  de- 
lirium acutum,  264 ;  in  Korsa- 
kow's  syndrome,  278,  282 ;  in 
manic-depressive  insanity,  349 ;  in 
neurasthenic  states,  537;  in  pa- 
resis, 434;  in  paretic  seizures, 
452 ;    in  senile  psychoses,  588. 

Re-perception,  58. 

Reproductions,    100. 

Rest  treatment,  150,  541. 

Rhachitis  fcetalis,  244. 


Rheumatism,    Acute   articular,   257, 

258. 
Rickets,  241. 
Rupophobia,  527. 


Sadismus,  108. 

Saline  infusions,  164;  in  acute  de- 
lirium, 265 ;  in  amentia,  274 ;  in 
paresis,  459,  460. 

Saturnism,  324. 

Scarlet  fever,  376,  387,  488. 

Schriftwage,  341. 

Self-accusation,  in  amentia,  269;  in 
melancholia,  522. 

Self-consciousness,  35. 

Semi-idiocy,  235. 

Senescence,    Mental    symptoms    of, 

575- 

Senile  dementia,  24,  593 ;  Differ- 
ential diagnosis  of,  597 ;  Forensic 
importance  of,  598;  Heredity  in, 
59°,  597 !  Pathological  changes 
in,  598 ;    Treatment  of,  598. 

Senile  epilepsy,  24. 

Senile  psychoses,  24,  216,  228, 
273,  483,  547,  548,  575;  Anxiety 
in,  369,  578,  585,  588,  590,  591, 
592,  596 ;  Apathy  in,  590 ;  Appre- 
hensiveness  in,  578,  579,  585,  586, 
588,  590,  soi,  592,  593,  596;  At- 
tention in,  585,  588,  595;  Blood- 
pressure  in,  588;  Consciousness 
in,  585,  588 ;  Course  of,  589 ;  De- 
lusions in,  580;  Depression  in, 
578,  579,  585,  590,  593,  594,  596; 
Differential  diagnosis  in,  590; 
Emotional  anomalies  in,  579,  595 ; 
Excitement  in,  578,  593;  Facial 
expression  in,  585,  596;  Feeling 
of  insufficiency  in,  579,  589;  Gas- 
tro-intestinal  disturbances  in, 
588,  597 ;  Grouping  of,  577 ;  Hal- 
lucinations in,  584,592,  593,  595, 
596;  Hypochondriasis  in,  578. 
580,  582,  584,  586,  593;  Impul- 
sivity  in,  593,  596;  Insane  ideas 
in,  584,  585,  589,  593,.  596;  In- 
sight in,  582 ;  Insomnia  in,  588 ; 
Irritability  in,  593,  595 ;  Memory 
in,  575,  585,  588,  595;  Motor 
restlessness  in,  586,  589,  591,  592, 
596;  Orientation  in,  585,  593-595.; 
Physical  symptoms  of,  588 ;  Prog- 
nosis in,  589;  Speech  in,  596; 
Suspiciousness  in,  595 ;  Treat- 
ment of,  591. 

Senility,  107,  204,  575,  576. 

Sensation,  27,  69,  88,  91,  94,  109,  ill, 
112. 


6i6 


INDEX 


Sensation,  Anomalies  of,  12,  29, 
51,  72,  73,  91 ;  in  acute  alcoholic 
hallucinosis,  302;  in  cocainism, 
323 ;  in  delirium  tremens,  292 ; 
in  dementia  praecox,  378,  381,  388, 
395;  in  epileptic  mania,  479;  in 
hysterical  delirious  states,  508 ;  in 
idiocy,  232,  234;  in  manic-depres- 
sive insanity,  342,  344;  in  myx- 
oedematous  alienation,  329;  in 
neurasthenic  states,  519;  in  pa- 
resis, 420,  423,  446,  448;  in  pa- 
retic seizures,  452;  Significance 
of,  32- 

Sensation,  Characteristics  of,  55 ; 
Methods  of  study  of,  52. 

Sensations,  Analysis  of,  6;  Sub- 
jective, 62. 

Sense  of  deficiency  in  dementia 
praecox,  381. 

Sense  of  duty  in  paresis,  426,  448. 

Sense  of  proportion  in  paresis,  426. 

Sense  of  reality,  37. 

Sense  of  recognition  in  hysteria, 
498. 

Sense  of  self-activity,  Perversion 
of,  35- 

Sense  of  self-consciousness,  Exag- 
geration of,  in  litigious  insanity, 
572. 

Sense  of  well-being,  47. 

Sense  perception,  54,  57;  Disturb- 
ances in,  56,  58;    Intensity  of,  54. 

Sense,  Stereometric,  in  paresis,  427. 

Sensibility,  Changes  in  organic,  71, 
199. 

Sensory  impressions,  28,  30,  31,  50, 
"3- 

Serum  treatment  of  epilepsy,  491. 

Sex  as  a  cause  of  insanity,   193. 

Sexual  impulses,  108;  in  alcoholic 
paranoiic  states,  305 ;  in  arterio- 
sclerotic psychoses,  553 ;  in  pa- 
resis, 427,  459;  in  senile  psy- 
choses, 596. 

Sexual  organs,  Sensory  disturb- 
ances of,  in  neurasthenic  states, 
520. 

Sexual  perversion,  530. 

Skin  in  acute  delirium,  264. 

Sleep,  49. 

"  Snouting  cramp,"  96,  382. 

Social  position  and  paresis,  419. 

Somnambulism,  411 ;  in  alcoholism, 
290 ;  in  delirium  tremens,  291 ; 
in  hysteria,  506. 

Sound  association,  75,  yy,  78. 

Speech,  in  alcoholic  paranoiic  states, 
306 ;  in  cerebral  syphilis,  458 ;  in 
cretinism,  331 ;     in   delirium  tre- 


mens, 294,  295 ;  in  dementia  prae- 
cox, 383,  385,  397;  in  epilepsy,  482, 
484;  in  hysteria,  504;  in  idiocy, 
232 ;  in  imbecility,  236 ;  in  Korsa- 
kow's  syndrome,  282 ;  in  manic- 
depressive  insanity,  350;  in  mi- 
graine, 221 ;  in  multiple  sclerosis, 
457)  544!  in  paraldehyde  intoxica- 
tion, 317;  in  paresis,  250,  407,  409, 
413,  430,  452,  455,  458;  in  paretic 
seizures,  451 ;   in  senile  psychoses, 

506- 

Speech  compulsion,  in  delirium  tre- 
mens, 295 ;  in  dementia  prascox, 
388 ;  in  epileptic  mania,  478 ;  in 
hepatic  disease,  217;  in  manic- 
depressive  insanity,  75,  340. 

Spiritualism,  30,  398. 

Stdbchenzellen  in  paresis,  471. 

Stadium  dementiae,  358. 

Stereotypies  in  dementia  paranoides, 
399;  in  dementia  praecox,  382, 
385,  386,  392,  395,  396,  400,  404, 
405,  407,  485.  510. 

Stereotypy,  96,  138,  140,  250. 

Strain,    368. 

Structural  changes  and  disorders  of 
function,  16. 

Stupor,  372,  536;  associated  with 
brain  abscess,  548 ;  in  bromism, 
323 ;  in  chloroform  psychoses, 
315;  in  delirium  acutum,  263;  in 
dementia  praecox,  386,  391,  392, 
394,  395,  396,  401 ;  in  epilepsy, 
290,  480;  in  hepatic  disease,  217; 
in  manic-depressive  insanity,  87, 
352 ;  in  morphinism,  318 ;  in  pa- 
resis,   444;     in    paretic    seizures, 

451- 

Subacute  states  of  delirium  and 
mental  confusion,  266. 

Subconscious  impressions,  50. 

Suggestibility,  in  delirium  tremens, 
294;    in  hysteria,  503. 

Suicidal  impulses,  107,  530;  in 
epilepsy,  474,  477 ;  in  morphinism, 
320;    in  paresis,  445. 

Suspiciousness,  12,  37,  45,  48,  98, 
216;  in  alcoholic  paranoiic  states, 
305 ;  in  arteriosclerotic  psychoses, 
552 ;  in  dementia  praecox,  379, 
381,  388;  in  myxcedematous 
alienation,  328 ;  in  paranoia,  571 ; 
in  paresis,  444;  in  senile  psycho- 
ses, 595. 

Sydenham's  chorea,  222. 

Syphilis,  130,  219,  240,  241,  253,  487, 
557;  Cerebral,  458;  complicating 
dementia  praecox,  229;  in  epi- 
lepsy,  488;     in   paresis,   417;     in 


INDEX 


617 


relation  to  mental  disease,  210, 
559- 

Syphilitic  infection  followed  by 
hysterical  symptoms,  229. 

Syphilitic  psychoses,  558;  Group- 
ing of,  559;  Pathology  of,  562; 
Treatment  of,  562. 

Syphilophobia,  560. 


Tabes,  Relation  of,  to  paresis,  450. 

Tabo-paresis,  324,  449. 

Taphophobia,  529. 

Temperature,  in  amentia,  269;  in 
dementia  praecox,  402 ;  in  manic- 
depressive  insanity,  348;  in  mor- 
phinism, 319;  in  paretic  seizures, 
451 ;    in  senile  psychoses,  588. 

Tenacity  of  the  attention,  50. 

Thought,  53. 

Tic,  Psychic,  in  chorea,  222. 

Tics,  95 ;  in  dementia  praecox,  396  ; 
in  imbecility,  95 ;  in  neuras- 
thenia, 516;  in  psychasthenic 
states,  526. 

Time  sense  in  delirium  tremens, 
294. 

Tobacco  intoxication,  323. 

Topoalgias,  520. 

Toxic  products,  Manner  of  action 
of,  23. 

Train  of  thought,  49;  in  dementia 
praecox,  381 ;  in  hysteria,  497, 
503 ;  in  manic-depressive  insanity, 
406. 

Trauma,  129,  130,  131,  201,  240,  241, 
262,  274,  298,  368,  457,  487,  488; 
Classification  of  cases  of  aliena- 
tion following,  204;  Forensic  im- 
portance of  hysterical  symptoms 
following,  502 ;  Histological 
changes  following,  202;  Hypo- 
chondriasis following,  203 ;  Irrel- 
evancy in  hysterical  disturbances 
of  consciousness  following,  511; 
in  paresis,  418,  425. 

Traumatic  psychoses,  Differentia- 
tion of,  from  dementia  paralyt- 
ica, 202. 

Treatment  of  mental  cases,  146. 

Tremor,  in  alcoholic  paranoiic 
states,  306 ;  in  cocainism,  322 ;  in 
dementia  praecox,  402;  in  de- 
lirium tremens,  295 ;  in  epi- 
lepsy, 484;  in  fear,  109;  in  ma- 
nic-depressive insanity,  117,  339; 
in  morphinism,  319;  in  multiple 
sclerosis,  457,  544;  in  paralde- 
hyde intoxication,  317;  in  pa- 
resis, 428,  446,  452;    in  psychas- 


thenic states,  529;  in  senescence, 
576;    in  syphilitic  psychoses,  561. 

Trophic  disturbances  in  paresis,  435, 
454- 

Tuberculosis,  62,  no,  129,  130,  219, 
240,  252,  270,  281,  309,  439,  487; 
and  infantilism,  243 ;  and  insan- 
ity, 210;    Euphoria  in,  210. 

Tuczek's  fibre  studies  in  paresis,  22. 

Typhoid  fever,  17,  no,  130,  225,  241, 
256,  257,  258,  262,  263,  274,  280, 
281,  376,  488. 

Unconsciousness,   70. 

Uraemic  delirium,  220. 

Urine,  in  acute  delirium,  264;  in 
arterio-sclerotic  psychoses,  553 ; 
in  delirium  tremens,  296;  in 
manic-depressive  insanity,  348 ;  in 
neurasthenic  states,  538;  in  non- 
myxcedematous  infantilism,  244; 
in  paresis,  436,  437;  in  recurrent 
mania  and  melancholia,  220;  in 
senile  psychoses,  589. 

Vascular  changes,  24;  in  sene- 
scence, 577. 

Vaso-motor  disturbances,  in  demen- 
tia praecox,  402 ;  in  paresis,  435  ; 
in  neurasthenic  states,  538. 

Verbigeration,  in  dementia  praecox, 
369,  385,  396,  397,  405,  408;  in 
epileptic  mania,  478,  484;  in  myx- 
cedematous  alienation,  328. 

Vertigo,  in  bromism,  323 ;  in  lead 
poisoning,  325 ;  in  senile  psy- 
choses,  597. 

Vigility  of  the  attention,  50,   51. 

Visual  disturbances  in  paresis,  432. 

Visual  hallucinations,  62,  65,  66; 
and  ocular  disease,  64;  in  acute 
delirium,  263 ;  in  chorea,  222 ;  in 
cocainism,  322,  323 ;  in  delirium 
tremens,  292 ;  in  dementia  prae- 
cox, 397;  in  epileptic  mania,  478; 
in  fever  deliria,  258;  in  Graves' 
disease,  334 ;  in  hepatic  disease, 
217 ;  in  hysteria,  496,  507 ;  in 
Korsakow's  syndrome,  279;  in 
meningitis,  547 ;  in  migraine,  221 ; 
in  morphinism,  318,  320;  in  myx- 
cedematous  alienation,  329 ;  in 
paraldehyde  intoxication,  316;  in 
paranoia,  571 ;  in  paresis,  439, 
443,  447,  452 ;  in  psychasthenic 
states,  531 ;    Unilateral,  63. 

Volition,  Disturbances  of,  87;  For- 
ensic importance  of,  92 ;  in  de- 
mentia   paranoides,    398;     in    de- 


6i8 


INDEX 


mentia  prsecox,  388;    in  hysteria, 

498;    in  neurasthenic  states,  519; 

in  paranoia,  570. 
Volitional  processes,  10,  52,  53,  120, 

123  ;  Definition  of,  90. 
Voluntary  patients,  176. 
Vorbeireden,    see   Irrelevancy. 

Wandering  mania,  47,  132,  196. 

Weber's   hypothesis,   54. 

Weight,  in  acute  delirium,  264;  in 
amentia,  270;  in  arteriosclerotic 
psychoses,  557;  in  dementia  prae- 
cox,  404;  in  hypomania,  356;  in 
manic-depressive  insanity,  348, 
365,  540;    in  paraldehyde  intoxi- 


cation, 316;  in  paresis,  436;  in 
senile  psychoses,  589. 

Will,  Freedom  of,  93. 

Witchcraft,  Belief  in,  30. 

"  Wonders,"  Arithmetical  or  Cal- 
culating, 237. 

Wort-salat,  383. 

Writing,  in  dementia  praecox,  383; 
in  manic-depressive  insanity,  341, 
351;    in  paresis,  43*- 


Zielvorstellung,  75. 
Zoophilia,  108. 

Zwangsvorstellungenpsy  chosen,  101, 
517. 


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